SERVICES	Co-Insurance Rate	Deductible
Preventive Care: Oral examination (periodic) two times per calendar year Oral examination (full mouth) one time in a five consecutive year period Prophylaxis (surface cleaning of the teeth), two times per calendar year. Topical application of fluoride for children under 19 years of age, not more than two (2) applications per person per calendar year. Dental X-rays: Full mouth set of X-rays including panograph (one set of panographs in each period of three consecutive calendar years). Bite-wings X-rays, two sets per calendar year (one set equals two X-rays if large, four X-rays if small) Space maintainers for children 12 years of age and under. Sealants for children 14 years of age and under.	100%	Waived
Basic Care: Extractions (non-orthodontic). Restorative-type fillings. General and local anesthetic when administered with oral surgery. Treatment of periodontal and other diseases of the gums and tissues. Endodontic treatment, including root canal, if tooth is “opened” while insured. Injection of antibiotic drugs. Recementing of crowns, inlays and bridgework Relining of dentures once every two years Emergency (palliative) treatment of dental pain-minor procedures Bleaching	80%	Individual $25 Family $100
Major Restorative Care: (One Year Waiting Period) Inlays, onlays, and crown restorations Initial installation of fixed bridgework. Installation of full or partial dentures.	50%	Individual $25 Family $100
Orthodontic Care:* (One Year Waiting Period) Orthodontic extractions. Services or supplies for orthodontic treatment, including necessary orthodontic appliances. Dental Benefits for orthodontic treatment and appliances apply to dependent children under the age of nineteen.	50% Lifetime Maximum $1,000	Individual $25 Family $100
CALENDAR YEAR MAXIMUM (per insured): $1,000 LATE ENROLLMENTS: Maximum allowed benefits will be reduced for late enrollments. If a member enrolls late, the maximum amount payable for covered dental expenses shall be reduced to $100 during the first 12 months of coverage. Also, the maximum payable for covered orthodontic expenses shall be reduced to $100 during the first 3 years of coverage. An enrollment is considered “late” if the member becomes covered more than 31 days after first becoming eligible to enroll for this coverage.

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