Dental 1.5
Dental 1.5 Plan provides coverage for Dental Services with $0 copays for preventative services
| Individual Annual Deductible |
$0 |
| Family Annual Deductible |
$0 |
| Individual Maximum Benefit |
$1,500 |
| Family Maximum Benefit |
$3,000 |
| Network |
Dentemax |
List of Services
| Preventative/Diagnostic Services |
Member Pays |
Limitations |
| Oral examinations |
0% Coinsurance |
1 per consecutive 6 month period |
| Cleanings Adult/Child |
0% Coinsurance |
1 per consecutive 6 month period |
| Fluoride |
0% Coinsurance |
1 per consecutive 6 month period |
| Sealants (permanent molars only) |
0% Coinsurance |
treatment per tooth per consecutive 36 month period |
| Bitewing Xrays |
0% Coinsurance |
1 set per consecutive 12 month period |
| Basic Restorative Services |
Member Pays |
Limitations |
| Full mouth series Xrays* |
20% Coinsurance |
A waiting period of 6 months applies in connection with all Basic Restorative Services. *1 per consecutive 60 month period |
| Restorative Amalgam or Composite |
20% Coinsurance |
| Routine Tooth Extraction |
20% Coinsurance |
| Major Restorative Services |
Member Pays |
Limitations |
| Endodontics |
50% Coinsurance |
A waiting period of 12 months applies in connection with all Major Restorative Services. |
| Periodontics |
50% Coinsurance |
| Dentures |
50% Coinsurance |
| Crowns |
50% Coinsurance |
| Complex Extraction |
50% Coinsurance |
| Local Anesthesia |
50% Coinsurance |
| Onlays |
50% Coinsurance |
| Implants |
50% Coinsurance |
See Exclusions & Limitations
The waiting period is the amount of time you must be enrolled in the plan before you are eligible to receive plan benefits for the treatments subject to
the waiting period. For example, you enrolled in coverage effective July 1, the plan will not cover any portion of the costs for a basic restorative service
until January 1 of the next year. The plan will not cover any portion of the costs for a major restorative service until July 1 of the next year.
The purpose of this list of exclusions is solely to provide additional clarity regarding treatments, procedures, products, services, or any other items which
are not covered under this plan. Accordingly, no exclusion shall be interpreted by negative implication, or otherwise, as evidence of the existence of
coverage under this plan.
