III – Dental Care

Dental Care Eligible Expenses - Basic Services

III

Dental Care

Reimbursement Percentage For Each Insured Person

Year One	Year Two	Year Three
50%	50%	50%

Annual Maximum for Each Insured Person

Basic Services (cleaning, recall exams)

Year One	Year Two	Year Three
$300	$300	$500	Maximum increases in year three

Where no maximum is stated, the Program reimburses 50% up to the usual and customary cost of these items:

Benefit Year – is 12 months from the effective date of coverage.

Procedure and Service Classification	Coverage Limits for Each Insured Person Benefit Year As Indicated on your Certificate of Insurance
Basic Services
Complete examination and full series of x-rays or panoramic films	Once every five Benefit Years or if a new dentist is involved in the Insured Person's Dental Care.
Recall examination by the dentist	Once every nine months.
Topical application of any anti-carcinogenic agent (e.g. stannous fluoride) or polishing of teeth	Once every nine months.
Routine diagnostic and laboratory procedures	Laboratory fees are limited to a maximum of 50% of the total cost of the dental procedures.
Prophylaxis, including deep scaling	10 units each Benefit Year. Pre-authorization for any additional units is required from the AFBS dental consultant.
Bitewing x-rays	Once each Benefit Year.
Oral hygiene instruction	Once each lifetime.
Fillings (amalgam, silicate, acrylic and composite), retentive pins and pit and fissure sealants	Covered up to the usual customary charges.
Space maintainers	Covered up to the usual customary charges.