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 Restorative Prosthodontics (teeth replacement) • One complete initial oral exam, including initial • Amalgam(silver)fillings(limitedtoonefillingfor • Complete or partial dentures (including services to dental history and charting of the teeth and each tooth surface in a 12-month period) fabricate,measure,fit,andadjustthem)onceeach supporting structures • Compositeresin(toothcolor)fillings(limitedtoone 60 months for each arch • FullmouthX-rays,sevenormorefilms,or fillingforeachtoothsurfaceina12-monthperiod) • Fixed bridges (including services to fabricate, panoramic X-ray with bitewing X-rays once each • Pinretentionforfillings measure,fit,andadjustthem)onceeach60 60 months • Stainlesssteelcrownsonbabyteethandonfirst months for each tooth • Bitewing X-rays twice per calendar year permanent adult molars (members under age 16) • Replacement of dentures and bridges once each • Single tooth X-rays as needed Oral Surgery 60 months when the existing appliance can’t be • Study models and casts used in planning treatment • Tooth extraction made serviceable once each 60 months • Root removal • Adding teeth to an existing bridge • Periodic or routine oral exams twice per calendar • Biopsies • Temporary partial dentures to replace any of the six year upper or six lower front teeth (only covered if they • Emergency exams Periodontics (gum and bone) are installed immediately following the loss of teeth Preventive • Periodontal scaling and root planing once per and during the period of healing) • Routine cleaning, scaling, and polishing of the teeth quadrant each 24 months Major Restorative (members age 16 or older) twice per calendar year • Periodontal surgery once per quadrant each 36 • Crowns, once each 60 months for each tooth • Fluoride treatment twice per calendar year months • Metallic, porcelain, and composite resin inlays. (members under age 19) • Periodontal maintenance following active Benefitsareprovidedforanamalgamfillingtoward • Sealants on permanent pre-molar and molar periodontal therapy once each three months the cost of a metallic, porcelain, or composite resin surfaces (members under age 14).Benefitsare Endodontics (roots and pulp) inlay, once each 60 months for each tooth. You pay provided for one application per bicuspid or molar • Root canal therapy (permanent teeth, once in a any balance. surface each 48 months. lifetime per tooth) • Metallic, porcelain, and composite resin onlays, once • Space maintainers needed due to premature tooth • Retreatment root canal therapy on permanent teeth, each 60 months for each tooth loss (members under age 19) once in a lifetime for each tooth • Replacement of crowns, once each 60 months for • Therapeutic pulpotomy on primary or permanent each tooth teeth (members under age 16) • Replacement of metallic, porcelain, and composite • Other endodontic surgery to treat or remove the resininlays.Benefitsareprovidedforanamalgam dental root fillingtowardthecostofametallic,porcelain,or Prosthetic Maintenance composite resin inlay, once each 60 months for • Repair of partial or complete dentures, crowns, and each tooth. You pay any balance. bridges once each 12 months • Replacement of metallic, porcelain, and composite • Adding teeth to an existing complete or resin onlays, once each 60 months for each tooth partial denture • Post and core or crown buildup, once each 60 • Rebase or reline of dentures once each months for each tooth 36 months Implants (members age 16 or older) • Recementingofcrowns,inlays,onlays,andfixed • Singletoothdentalendostealimplants(thefixture bridgework once each 12 months and abutment portion) in addition to the allowance Other Services for the crown for the implant, once each 60 month • Occlusal adjustments once each 24 months period, when the implant replaces permanent teeth • Services to treat root sensitivity through the second molars • General anesthesia when administered in Orthodontic Benefit Group conjunction with covered surgical services • Emergency dental care to treat acute pain or to Full coverage* prevent permanent harm to a member** 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.