Diagnostic and Preventive. Services Initial and periodic oral exams and cleanings Topical application of fluoride Space maintainers X-rays Emergency Treatment Prophylaxis Space Maintainers Payable at 100% of usual, customary and reasonable charges at participating dentists.
Diagnostic and Preventive. X-Ray and Laboratory Tests For pre-admission tests, eighty percent (80%) when using a network provider. When using a non- network provider, sixty percent (60%) of UCR/Allowed Amount. When using a network hospital, eighty percent (80%) of charges. When using a non-network hospital, sixty percent (60%) of UCR/Allowed Amount. Deductibles apply. One hundred percent (100%) coverage after OPM is reached.
Diagnostic and Preventive. Services Initial and periodic oral exams and gs Topical application of fluoride Space maintainers X-rays Emergency Treatment Prophylaxis Space Maintainers Payable at 100% of usual, customary and reasonable charges at participating dentists. Basic Services Fillings Root Canals Stainless steel crowns Extractions Oral Surgery Repair and relining of dentures Apicoectomy Inlays 1/tooth/5 years Onlays 1/tooth/5 years Crowns 1/tooth/5 years Payable at 80% of usual, customary and reasonable charges at participating dentists.
Diagnostic and Preventive. Oral Exam You pay nothing You pay nothing Preventive - Cleaning You pay nothing You pay nothing Preventive - X-ray You pay nothing You pay nothing Sealants per Tooth You pay nothing You pay nothing Topical Fluoride Application You pay nothing You pay nothing Space Maintainers – Fixed You pay nothing You pay nothing Basic Services 18 Restorative Procedures See Dental Copay Schedule in Evidence of Coverage You pay nothing Periodontal Maintenance Services You pay nothing Major Services 18 Crowns and Casts See Dental Copay Schedule in Evidence of Coverage You pay nothing Endodontics You pay nothing Periodontics (other than maintenance) You pay nothing Prosthodontics You pay nothing Oral Surgery You pay nothing Orthodontics 18, 19 Medically Necessary Orthodontics $1,000 You pay nothing Summary of Benefits Endnotes: 1 Copayments or Coinsurance for Covered Services accrue to the Calendar Year Out-of-Pocket Maximum, except Copayments or Coinsurance for Covered Services listed in the following sections of this Summary of Benefits: Charges in excess of specified benefit maximums Note: Copayments, Coinsurance, and charges for services not accruing to the Calendar Year Out-of-Pocket Maximum continue to be the Member's responsibility after the Calendar Year Out-of-Pocket Maximum is reached. 2 Any Coinsurance is calculated based on the Allowed Charge unless otherwise specified.
