Preventive - 100% no waiting period:

Periodic Exams (2 per year), Bitewing X-rays, Prophylaxis (cleaning and scaling), Space Maintainers, Fluoride treatments for children and Sealants

Radiographs - FMX - 60% No Waiting Period

Full Mouth or Panoramic X-rays

Basic - 60% no waiting period:

Palliative (emergency) Treatment of Dental Pain, Simple Extractions, X-rays (Intraoral Periapical, Extraoral, Vertical Bitewings, and Sialography)

Basic Restorative - 60% no waiting period

Amalgams and Resin-Based Composites

Major - 40% after twelve (12) month waiting period:

Inlay, Onlay, Crown, Fixed Partial Denture (bridge), Partial Denture, and Complete Denture

Endodontics - 40% after twelve (12) month waiting period:

Root Canal (Anterior, Bicuspid, and Molar) Therapeutic Pulpotomy

Periodontics - 40% after twelve (12) month waiting period:

Gingivectomy, Osseous Surgery, Periodontal Scaling and Root Planing

PROSTHODONTIC REPAIRS - 40% After twelve (12) month waiting period:

Rebase, Reline, Repair Broken Clasp, and Repair Cast Framework

$50.00 Calendar/Policy Year Deductible - Deductible is per person with a maximum of 3 individual deductibles per family per year. The $50 calendar/policy year deductible for Preventive, FMX-Radiographs, Basic, Basic Restorative, Major, Endodontics, Periodontics, Prosthodontic Repairs, and Oral Surgery is combined

Calendar Year Maximum -  $1,250

EXCLUSIONS

1. Services which are not included in the Schedule of Covered Dental Services and Procedures; which are not Necessary Services; or which a charge would not have been made in the absence of insurance; and,

2. Any Service, which may not reasonably be expected to successfully correct the patient's dental condition for a period of at least 3 as determined by Us; and,

3. Crowns, inlays, onlays, cast restorations, or other laboratory prepared restorations on teeth, which may be satisfactorily restored with amalgam or composite resin filling; and,

4. Appliances, inlays, cast restorations, crowns, or other laboratory prepared restorations used primarily for the purpose of splinting; and,

5. Any Service or appliance, the sole or primary purpose of which relates to the change or maintenance of vertical dimension; and,

6. Any Service provided primarily for cosmetic purposes. Facings on crowns or bridge units on molar teeth shall always be considered cosmetic; and,

7. The initial placement of a removable full denture or a removable partial denture unless it includes the replacement of a Functioning Tooth extracted while the Person is insured under the Policy; and,

8. The initial placement of a fixed partial denture including a Maryland Bridge, unless it includes the replacement of a Functioning Natural extracted while the Person is insured under the Policy, provided that tooth was not an abutment to an existing partial denture that is less than 5 years old or to an existing fixed partial denture or Maryland Bridge which is less than 7 years old. Benefits are payable only for the replacement of those teeth which were extracted while the Person was insured under the Policy; and,

9. Replacement of a partial denture, full denture, or fixed partial denture (including a Maryland bridge) or the addition of teeth to a partial denture unless:

   1. Replacement occurs at least 5 years after the initial date of insertion of the current full or partial denture; or,

   2. Replacement occurs at least 7 years after the initial date of insertion of an existing fixed partial denture or Maryland bridge; or,

   3. The replacement prosthesis or the addition of a tooth to a partial denture is required by the Necessary extraction of a Functioning Natural Tooth while the Person is insured under the Policy, provided that tooth was not an abutment to an existing partial denture that is less than 5 years old or to an existing fixed partial denture or Maryland bridge that is less than 7 years old; or,

   4. The replacement is made Necessary by a Covered Dental Injury provided the replacement is completed within 6 months of the Chewing Injuries are not considered Covered Dental Injuries.

10. The replacement of crowns, cast restorations, inlays, onlays or other laboratory prepared restorations within 7 years of the date of insertion; and,

11. Replacement of a bridge, partial denture, full denture, crown, cast restoration, inlay, onlay or other laboratory prepared restoration can be restored to function; and,

12. The replacement of teeth beyond the normal complement of 32; and,

13. Implant placement or removal and all Related Services; and,

14. Crowns, fixed partial dentures and any dental prosthesis for placement on or supported by implants; and,

15. The replacement of an existing removable partial denture with a fixed partial denture unless upgrading to a fixed partial denture is essential to the correction of the Insured Person's dental condition; and,

16. Athletic mouth guards; myofunctional therapy; infection control; precision or semi-precision attachments; denture duplication; oral instruction; separate charges for acid etch; treatment of jaw fractures; orthognathic surgery; exams required by a third party other than Us, personal supplies (e.g., water pik, toothbrush, floss holder, etc.); or replacement of lost or stolen appliances; and,

17. Charges for travel time; transportation costs; or professional advice given on the phone; and,

18. Orthodontic treatment (unless the Policy includes the orthodontic expense rider); and,

19. Services that are a covered expense under any other plan that is provided by the Policyholder and for which You are eligible; and,

20. Services performed by a Dentist who is member of the Insured Person's family. Insured Person's family is limited to a spouse, siblings, parents, children, grandparents, and the spouse's siblings and parents; and,

21. Any charges, including ancillary charges, made by a hospital, ambulatory surgical center or similar facility; and,

22. Any charges in excess of the Usual, Customary and Reasonable charge for any covered dental Service or procedure; and,

23. Any charges for appointments not kept; and,

24. Any charges for completion of claim forms; and,

25. Any charges for services performed or started prior to the date the Insured Person became insured hereunder; or the charges incurred following termination of insurance; and,

26. Cost of Pharmaceuticals; and,

27. TMJ (Temporomandibular Joint) Treatment or Services or supplies rendered for full mouth reconstruction or vertical dimension unless the policy includes the TMJ Expense Rider; and,

28. Dental treatment not approved by the American Dental Association or which is clearly experimental in nature; and,

29. Services or supplies rendered for dietary planning for the control of dental caries, plaque or for oral hygiene instruction; and,

30. Services or supplies provided by or paid for any government or government employed Dental Practitioner, unless the Covered Person is a recipient of Medicaid and/or is legally required to pay for such Services or supplies;

31. Any treatment not prescribed by a dentist or physician or not performed by a Dental Practitioner; and,

32. Congenitally missing teeth unless a retained deciduous tooth is extracted while the person is insured; and,

33. Local anesthetic as a separate fee; and,

34. Any charge for a Service performed outside of the United States other than for Emergency Treatment. Benefits for Emergency performed outside of the United States are limited to a maximum of $100 per year; and,

35. Any charge for a Service required as a result of disease or injury that is due to war or an act of war (whether declared or undeclared); taking part in an insurrection or riot; the commission or attempted commission of a crime; an intentionally self-inflicted injury or attempted suicide while sane or insane; and,

36. Any charge for a Service for which benefits are available under Worker’s Compensation or an Occupational Disease Act or Law, if the Insured Person did not purchase the coverage that is available to Him/Her;

37. Any Service for which the Insured Person is not required to pay unless the payment of benefits is mandated by law and then only to extent required by law; and,

38. Any treatment plan which involves full-mouth reconstruction by the removal and reestablishment of occlusal contacts of 10 or more with restorations, crowns, onlays, inlays, fixed partial dentures, dentures, or any combination of these services.