Dental Care

Eligible Dental Care Expenses

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.

Dental Care Eligible Expenses - Periodontal, Endodontic, Major Restorative 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

Periodontal
(gum disease)
Endodontic
(root canal)
Major Restorative Services
(crowns, bridges, dentures)

Year One	Year Two	Year Three
$500	$500	$750	Maximum increases in year three

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

Periodontal, Endodontic and Major Restorative Services
Periodontal – Treatment of diseases of the gums and other supporting tissue of the teeth (excluding splinting), including surgery and post surgical treatment and appliances	Periodontal appliances are limited to once every 24 months per arch.
Root canal therapy, root amputation, apexification (end of the root) and periapical services (surrounding bottom of the root of a tooth)	Covered up to the usual customary charges.
Oral surgical procedures including the removal of teeth	Covered up to the usual customary charges.
General anesthesia and x-rays	X-rays are limited to three each Benefit Year. General anesthetic is paid in conjunction with eligible oral surgical procedures.
Crowns, inlays and onlays	Only when the function is impaired due to cuspal or incisal angle damage caused by trauma or decay.
Replacement of crowns, inlays and onlays	Once every five Benefit Years.
Implants	Reimbursement may be limited to that of the generally accepted alternative. Costs may not be applied across Benefit Years.
Initial provision for fixed bridgework	Covered up to the usual customary charges.
Replacement of fixed bridgework or additional teeth to bridgework	When replacement or addition is due to one of the following: 1. A natural tooth is extracted and the existing appliance cannot be made serviceable. 2. The existing appliance is at least five years old and cannot be made serviceable. 3. The existing appliance is temporary and within 12 months of its installation a permanent bridge replaces it. The total amount payable for both the temporary and permanent bridge is the amount which would have been allowed for a permanent bridge.
Initial provision of full or partially removable dentures	Covered up to the usual customary charges.
Repair or re-cementing of crowns, onlays, inlays, bridgework and dentures, or relining and rebasing of dentures	Covered up to the usual customary charges.
Replacement of removable dentures	When dentures are necessary due to one of the following: 1. A natural tooth is extracted and the existing appliance cannot be made serviceable 2. The existing appliance is at least five years old and cannot be made serviceable 3. The existing appliance is temporary and within 12 months of its installation a permanent denture replaces it. The total amount payable for both the temporary and permanent dentures is the amount which would have been allowed for a permanent denture.
Addition of teeth to an existing partial denture or fixed bridgework previously removed	When required to replace one or more teeth.
Procedures involving the use of gold	Only when there is no alternative consistent with generally accepted dental practice.

Limitations are generally accepted guidelines, but where a situation is warranted, a review by the AFBS dental consultant may be requested.

Claims for some procedures, including full series of x-rays and panoramic films and major restorative work cannot be processed electronically. When claims are not processed electronically a standard dental claim form must be submitted to AFBS.

Program Handbook