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Dental |
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Dental Care*
Insurer: Self-Insured
Policy #: 9000
Benefits:
- Basic: 80%
- Major: 80%
- Basic & Major Combined Maximum: $2500 / yr
per member and eligible dependents
-
Orthodontia 50% Lifetime maximum $2500 for
dependent children only
Basic coverage includes preventative and restorative
services such as:
- oral examinations
- dental x-rays
- teeth cleaning
- topical application of fluoride and other
anticariogenic substances
- treatment of periodontal and other diseases of the
gums and mouth tissues
- application of pit and fissure sealant
- initial provision & replacement of amalgam,
silicate, acrylic or composite restoration
- endodontic treatment, including root canal therapy
- relining, or rebasing dentures, or adjustments to
dentures if a 6-month period has elapsed since the date
the dentures were provided
Major coverage includes major restorative services such
as:
- initial provision of crowns (other than stainless
steel crowns) or gold inlays
- replacement of crown (other than stainless steel
crowns)
- initial installation of full dentures, or partial
dentures if required to replace natural tooth/teeth that
were extracted after the effective date of the member's
coverage
- addition of teeth to existing dentures
- addition of teeth to fixed bridgework.
*An employee can waive these benefits if that individual
provides proof that he/she has comparable benefits through
their spouse's plan. If no proof is provided all benefits
will be considered mandatory.
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