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| The Dental / Vision Plan Benefits can be added to
either the Value or Enhanced Plan. Members may also elect this coverage on a stand
alone basis to complement other health coverage in force. |
| Dental/Vision Plan Summary |
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Dental Care
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$2,000 annual maximum
$500 periodontics maximum
$1,000 orthodontics maximum
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Vision
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$45 / annual exam
$100 set of frames/lenses
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Vision Benefits: $45 per eye exam per covered person per
calendar year and $100 toward a set of frames and
lenses or contact lenses per covered person once every two calendar years.
Dental Benefits:
Scheduled amounts are payable up to $2,000 per covered person per calendar year for preventative and
diagnostic care, restorative treatment, root canals, periodontics ($500 lifetime maximum), oral surgery
and orthodontia ($1,000 maximum per course of treatment). Some benefits require a 12 month waiting
period before benefits are available. (See Schedule of Benefits below)
|
| Dental Plan Schedule of
Benefits |
| Procedure |
Insurance
Pays |
| Type 1: Preventive &
Diagnostic |
|
| a. Oral exams, including
prophylaxis |
$ |
48.00 |
| b. Bitewings, per film |
$ |
6.40 |
| c. X-ray, panoramic or
cephalometric |
$ |
48.00 |
| d. Sealants, topical fluoride |
$ |
13.60 |
| e. Space maintainers |
$ |
144.00 |
| Type 2: Major Restorative |
|
| a. Crowns, dentures &
bridges |
$ |
240.00 |
| b. Pre-fabricated crowns |
$ |
80.00 |
| c. Crown build-up procedures |
$ |
64.00 |
| Type 3: Minor Restorative |
|
| a. Fillings |
$ |
56.00 |
| b. Crown, bridge, and denture
repairs |
$ |
32.00 |
| c. Relining or rebasing
dentures |
$ |
80.00 |
| Type 4: Endodontics |
|
| a. Root canals, apicoectomies |
$ |
256.00 |
| b. Root amputation |
$ |
128.00 |
| c. Therapeutic pulpotomy,
retrograde fillings, apexification, hemisection |
$ |
64.00 |
| Type 5: Periodontics ($500
Lifetime Maximum) |
|
| a. Tissue grafts or bone
surgery |
$ |
128.00 |
| b. Gingivectomy (per
quadrant), periodontal scaling, periodontal splinting, root planning |
$ |
80.00 |
| c. Gingival curettage (per
quadrant) |
$ |
48.00 |
| d. Gingivectomy (per tooth) |
$ |
32.00 |
| Type 6: Oral Surgery |
|
| a. Surgeries Level 1 (ex.
Removal of exostosis) |
$ |
160.00 |
| b. Surgeries Level 2 (ex.
Removal of impacted tooth) |
$ |
88.00 |
| c. Surgeries Level 3 (ex.
Simple extraction) |
$ |
48.00 |
| Type 7: General Anesthesia
and IV |
|
| a. IV, first half hour
general, each additional 1/4 hour general |
$ |
96.00 |
| Type 8: Orthodontia (Per
Course of Treatment) |
$ |
1000.00 |
| |
Types 1 through 7 subject to annual maximum
of: $ 2,000
Types 2, 5, 6a, 7 and 8 are subject to: 12 month waiting period
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