Enhanced Plan Summary

The enhanced dental plan's maximum benefit per person on the plan is $1,500 per year, which includes annual cleanings and x-rays. The plan covers services based on the following details.

Plan Services and Costs
Service Plan Pays You Pay
Diagnostic and preventive 100% 0%
Emergency palliative treatment 100% 0%
Brush biopsy 100% 0%
Radiographs (x-rays) 100% 0%
Periodontal maintenance 100% 0%
Minor and major restorative 80% 20% (after $50 per year deductible)
Endodontic 80% 20% (after $50 per year deductible)
Periodontic 80% 20% (after $50 per year deductible)
Oral surgery 80% 20% (after $50 per year deductible)
Relines and repairs 80% 20% (after $50 per year deductible)
Prosthodontic 65% 35% (after $50 per year deductible)
Orthodontics
Orthodontic age limit is age 24 for dependent children.
Orthodontic lifetime limit per person is $1,500.
50% 50%

Additional Details

  • Oral exams (including evaluations by a specialist) are payable twice per calendar year.
  • Prophylaxes (cleanings) are payable twice per calendar year.
  • People with certain high-risk medical conditions may be eligible for additional prophylaxes (cleanings) or fluoride treatment. The patient should talk with his or her dentist about treatment.
  • Fluoride treatments are payable twice per calendar year with no age limit.
  • Bitewing X-rays are payable once per calendar year and full mouth X-rays (which include bitewing X-rays) are payable once in any five-year period.
  • Composite resin (white) restorations are Covered Services on posterior teeth.
  • Porcelain crowns are optional treatment on posterior teeth.
  • Implants and implant related services are payable once per tooth in any five-year period.