| 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. |