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Benefit information
Your group dental policy provides benefits for preventive and diagnostic dental services as well as basic services for the treatment of dental disease and injury. For detailed information about these services, please refer to Sections 5 and 6 of your policy. In addition, you may be entitled to one or more optional benefits, which are described in Section 7 of the policy.
The following is a summary of the services covered by your policy:
Preventive services
We cover the following preventive services during each Benefit Period:
- Two periodic oral examinations.
- Two sets of bitewing X-rays.
- Two prophylaxes (cleaning of teeth).
- Two in-office topical applications of fluoride for covered dependent children under 19.
In addition, we cover sealants applied once every five years to the bicuspids and molars of covered dependent children under 17.
Diagnostic services
We cover the following medically necessary diagnostic dental services:
- One panoramic X-ray, full mouth X-ray, or full mouth series, but only once in any consecutive 24-month period.
- Periapical X-rays.
- X-rays necessary for diagnosing and providing covered treatment of dental disease or injury.
- Pulp vitality tests.
- Office visits or consultations in conjunction with covered services.
Basic services
We cover the following diagnostic dental services when we find them to be medically necessary, medically appropriate, and cost-effective as those terms are defined in Section 4 of your policy:
- Amalgam fillings.
- Composite/resin fillings on any tooth except a molar.
- Extraction of teeth.
- Oral surgery.
- Stainless steel crowns.
- Local or general anesthesia or analgesia administered in connection with a covered service.
- Space maintainers for covered dependent children under 19.
- Pulpotomies and root canal therapy.
- Periodontal treatment.
- Denture repair.
- Bruxism appliances.
In addition to these services, we reimburse for occlusal adjustments up to a $100 lifetime maximum for each covered individual.
Optional Benefits
Section 7 of the group dental policy describes three optional dental benefits: 1) onlays and crowns; 2) dentures, bridgework, and implants; and 3) orthodontics. If one or more of these optional benefits are included in your dental coverage, they will be listed on your Benefit Summary under “Optional Benefits.” Please refer to your policy for specific information about covered and noncovered services related to these optional benefits.
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