Dental Blue freedom with Orthodontics Preventive Benefit Group Basic Benefit Group Major Benefit Group No Deductible $50 Per Member/$150 Per Family Calendar Year Deductible** (in-network and out-of-network combined) Full Coverage* 80% Coverage* 50% Coverage* $1,500 Per Member Calendar-Year Benefit Maximum (in-network and out-of-network combined) Diagnostic • One complete initial oral exam, including initial dental history and charting of the teeth and supporting structures • FullmouthX-rays,sevenormorefilms,or panoramic X-ray with bitewing X-rays once each 60 months • Bitewing X-rays twice per calendar year • Single tooth X-rays as needed • Study models and casts used in planning treatment once each 60 months • Periodic or routine oral exams twice per calendar year • Emergency exams Preventive • Routine cleaning, scaling, and polishing of the teeth twice per calendar year • Fluoride treatment twice per calendar year (members under age 19) • Sealants on permanent pre-molar and molar surfaces (members under age 14).Benefitsare provided for one application per bicuspid or molar surface each 48 months. • Space maintainers needed due to premature tooth loss (members under age 19) Restorative • Amalgam(silver)fillings(limitedtoonefillingfor each tooth surface in a 12-month period) • Compositeresin(toothcolor)fillings(limitedtoone fillingforeachtoothsurfaceina12-monthperiod) • Pinretentionforfillings • Stainlesssteelcrownsonbabyteethandonfirst permanent adult molars (members under age 16) Oral Surgery • Tooth extraction • Root removal • Biopsies Periodontics (gum and bone) • Periodontal scaling and root planing once per quadrant each 24 months • Periodontal surgery once per quadrant each 36 months • Periodontal maintenance following active periodontal therapy once each three months Endodontics (roots and pulp) • Root canal therapy (permanent teeth, once in a lifetime per tooth) • Retreatment root canal therapy on permanent teeth, once in a lifetime for each tooth • Therapeutic pulpotomy on primary or permanent teeth (members under age 16) • Other endodontic surgery to treat or remove the dental root Prosthetic Maintenance • Repair of partial or complete dentures, crowns, and bridges once each 12 months • Adding teeth to an existing complete or partial denture • Rebase or reline of dentures once each 36 months • Recementingofcrowns,inlays,onlays,andfixed bridgework once each 12 months Other Services • Occlusal adjustments once each 24 months • Services to treat root sensitivity • General anesthesia when administered in conjunction with covered surgical services • Emergency dental care to treat acute pain or to prevent permanent harm to a member** Prosthodontics (teeth replacement) • Complete or partial dentures (including services to fabricate,measure,fit,andadjustthem)onceeach 60 months for each arch • Fixed bridges (including services to fabricate, measure,fit,andadjustthem)onceeach60 months for each tooth • Replacement of dentures and bridges once each 60 months when the existing appliance can’t be made serviceable • Adding teeth to an existing bridge • Temporary partial dentures to replace any of the six upper or six lower front teeth (only covered if they are installed immediately following the loss of teeth and during the period of healing) Major Restorative (members age 16 or older) • Crowns, once each 60 months for each tooth • Metallic, porcelain, and composite resin inlays. Benefitsareprovidedforanamalgamfillingtoward the cost of a metallic, porcelain, or composite resin inlay, once each 60 months for each tooth. You pay any balance. • Metallic, porcelain, and composite resin onlays, once each 60 months for each tooth • Replacement of crowns, once each 60 months for each tooth • Replacement of metallic, porcelain, and composite resininlays.Benefitsareprovidedforanamalgam fillingtowardthecostofametallic,porcelain,or composite resin inlay, once each 60 months for each tooth. You pay any balance. • Replacement of metallic, porcelain, and composite resin onlays, once each 60 months for each tooth • Post and core or crown buildup, once each 60 months for each tooth Implants (members age 16 or older) • Singletoothdentalendostealimplants(thefixture and abutment portion) in addition to the allowance for the crown for the implant, once each 60 month period, when the implant replaces permanent teeth through the second molars Orthodontic Benefit Group Full coverage** No deductible • Complete orthodontic exam • Comprehensive or limited active orthodontic treatment, including appliances $2,000 Lifetime Benefit Maximum * Benefitsarereducedby20percentwhenservicesarereceivedfromanout-of-networkdentist. ** Emergency care services are not subject to the calendar-year deductible. Whenyourequireemergencycarebyanout-of-networkdentist,benefitsareprovidedatthesamelevelasan in-network dentist. For members under age 13, benefits (except for orthodontic services) are covered in full up to the calendar-year benefit maximum and are not subject to the deductible.