EMPLOYEE DENTAL PLAN
DENTAL EXPENSE BENEFITS
Annual Individual Deductible
Annual Family Deductible
Benefit Percentage for Dental Expenses
Class I (Diagnostic and Preventive Services)
Class II (Basic Restorative Services)
Class III (Major Restorative Services)
Class IV (Orthodontia; limited to unmarried
Dependent children up to age nineteen )
Maximum Annual Benefit per Individual
Classes I, II & III Combined
Maximum Lifetime Benefit per Individual
$1,500 per individual; limited to unmarried
Dependent children up to age nineteen (19)
An individual will only be eligible for Class I and Class II services for the first twelve (12) continuous months of coverage. After twelve (12) continuous months of coverage, an individual will be eligible for all classes of coverage. This limitation will not apply to charges as a result of accidental injury. When an individual becomes covered under the Plan, he must remain on the Plan for at least twelve (12) consecutive months unless he no longer meets the definition of an Eligible Participant.
COMPREHENSIVE DENTAL EXPENSE BENEFITS
Subject to the General Limitations and Exclusions of this Plan, usual, customary and reasonable
charges incurred for the following dental expenses will be covered in accordance with the
percentage of coverage, Deductible amounts and maximums in the Plan Summary. The Deductible
The Deductible is the amount of covered dental expenses which must be paid before Comprehensive Dental Expense Benefits are payable. The amount of the Deductible is shown in the Plan Summary. Each Family member is subject to the Deductible up to the Family maximum as shown in the Plan Summary.
Dental Eligible Expenses
The term "Covered Dental Expenses" means the expenses incurred by or on behalf of a Covered Individual for charges made by a Dentist for the performance of dental service provided for in the Plan Summary when the dental service is performed by or under the direction of a Dentist, is essential for the necessary care of the teeth, and begins while the Covered Individual is covered for Dental Benefits. If the actual performance of a dental service begins on a date other than the date the service was recommended or determined to be necessary, the dental service will be considered to begin on the date the actual performance of the service begins. For an appliance or modification of an appliance, an expense is considered incurred at the time the impression is made. For a crown, bridge, or gold restoration, an expense is considered incurred at the time the tooth or teeth are prepared. For root canal therapy, an expense is considered incurred at the time the pulp chamber is opened. All other expenses are considered incurred at the time a service is rendered or a supply furnished. Covered dental expenses do not include any expenses that are in excess of the reasonable and customary amount.
CLASS I - Diagnostic & Preventive Services
1. Oral examinations and routine cleaning (prophylaxis) of teeth, but not more than twice per
2. Fluoride applied to the teeth, but not more than once per calendar year.
3. Sealants, but limited to unmarried Dependent children up to age fifteen (15), and limited to
once per permanent first and second molars in a lifetime. (Sealants for primary teeth, wisdom teeth or teeth that have already been treated with a restoration are not eligible for this benefit.)
a. Full mouth (single or multiple films), but not more than once every three (3) years;
b. Bitewing x-rays, but not more than twice per calendar year.
c. Periapical, occlusal and extra oral x-rays when dentally necessary and appropriate.
CLASS II - Basic Restorative Services
1. Oral surgery, including pre- and post-operative care, general anesthesia, local anesthetic and
3. Regular cavity fillings, including amalgam, synthetic porcelains, composite and plastic fillings
4. Local anesthesia or analgesia in connection with a covered procedure.
8. Denture repairs and relines, except denture relines will not be covered more than once every
firs (5) years of it the original denture is less than five (5) years old.
9. Repairs and recementing of crowns, inlays, or bridgework.
10. Therapeutic drug injection (decadron).
12. Prescription drugs prescribed by a Dentist. CLASS III - Major Restorative Services
1. Bridges and partial or full dentures. The replacement of a bridge or denture is covered only
when dentally necessary and not more than once every five (5) years. The original placement of a bridge or denture (full or partial) is only allowable if the teeth were extracted while coverage was in effect under the Plan.
2. Surgical treatment for gum and bone diseases according to the following:
Flap entry and closure is considered part of the dental service for osseous surgery and osseous graft; and
b. If more than one surgical service is performed per quadrant, only the most inclusive
surgical service performed will be considered an eligible dental service.
3. Cast restorations for advanced tooth decay or fracture are allowable once every five (5)
consecutive years beginning from the date the cast restoration was cemented in place. Restorations include inlays, onlays, and crowns (including porcelain, porcelain fused, or precious metal crowns and related post and core). Crowns placed for the primary purpose of periodontal splinting, altering vertical dimension or restoring occlusion are not an Eligible Expense.
CLASS IV - Orthodontics
Services for the proper alignment of teeth, limited to unmarried Dependent children up to age nineteen (19).
1. Charges for services or supplies which have the primary purpose of improving the
appearance of the teeth, rather than restoring or improving dental form or function. Some examples include: laminate and veneers.
2. Charges for infection control procedures (sepsis control - rubber gloves, gowns, etc.)
when billed separately from actual dental treatment.
3. Charges for oral hygiene, dietary instruction or plaque control programs.
4. Charges for services or supplies provided by a Dentist who is a Close Relative.
6. Charges for services or supplies you are not legally obligated to pay for and for which
you would not be charged in the absence of this certificate.
7. Charges for the replacement of lost or stolen appliances.
8. Charges for services or supplies that you are entitled to claim from any governmental
program even if you waived or failed to claim rights to such services, benefits, or damages.
9. Charges for services or supplies not specifically listed as a covered expense.
10. Charges relating to TMJ (temporomandibular joint disorder).
11. Charges for services or supplies for crowns placed for the primary purpose of
periodontal splinting, altering vertical dimension, or restoring the closing of the upper and lower teeth (occlusion).
12. Charges for a missed appointment or completion of a form.
13. Charges for any service or supply that could have been compensated under Workers'
Compensation laws, including any services or supplies applied toward the satisfaction of any Deductible under your employer's Workers' Compensation coverage.
14. Charges for services or supplies for any treatment plan when you receive the services
or supplies after the date of termination of coverage under this Plan.
15. Charges for services or supplies related to a service that began prior to the effective
When an individual becomes covered for Dental benefits, he will only be eligible for Class I and Class II services for the first twelve (12) continuous months of coverage. After twelve (12) continuous months of coverage, an individual will be eligible for all classes of coverage. This limitation will not apply to charges as a result of accidental injury. When an individual becomes covered under the Plan, he must remain on the Plan for at least twelve (12) consecutive months unless he no longer meets the definition of an Eligible Participant.
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