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Download PDF of Standard Orthodontics coverage details
Benefit Maximum:
Per Person, Per Calendar Year: $1800
Deductible:
(applies to Type 2 and 3 services only)
Per Person, Per Calendar Year: $50
Type 1 deductible waived
No family maximum
Type 1 Services - No Waiting Periods
- Routine Oral Exams - Once every 6 Months.
- Routine Dental Cleaning - Once every 6 Months.
- Bitewing X-Rays - once every 12 months.
- Full Mouth or Panoramic X-Rays - Once every 5 years.
- Periapical X-Rays
- Flouride treatments - For children 13 and under. One per benefit period.
- Sealants - Ages 13 and under.
- Space maintainers
Type 2 Services - No Waiting Periods
- Restorative Amalgams
- Restorative Composites
- Endodontics - nonsurgical
- Endodontics - surgical
- Periodontics - nonsurgical
- Periodontics - surgical
- Denture Repair
- Simple extractions
Type 3 Services - No Waiting Periods
- Onlays
- Crowns - 1 in 10 years per tooth.
- Crown Repair
- Implants
- Prosthodontics - fixed bridge; removable complete/partial dentures covered once per 10 years.
- Complex Extractions
- Anesthesia