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planb

Dental Plan B Coverage

Type of Service

Diagnostic and Preventive Services

Year 1

Year 2

Year 3+

Oral examinations - twice in any benefit period

100%

100%

100%

Routine prophylaxis - twice in any benefit period

100%

100%

100%

Topical fluoride for patients under age 14 - once in any benefit period

100%

100%

100%

Sealants - once in 5 years for caries-free occlusal surfaces of the first & second permanent molars (only for children under age 16)

100%

100%

100%

Space maintainers - once in 5 years that replace prematurely lost teeth (only for children under age 16)

100%

100%

100%

Emergency palliative treatment - as needed

100%

100%

100%

Bitewing x-rays - one set in any benefit period

100%

100%

100%

Basic Services

Year 1

Year 2

Year 3+

Periapical x-rays - as required

80%

80%

80%

Filings - restorative services using amalgam, synthetic porcelain and plastic material

80%

80%

80%

Simple extractions

80%

80%

80%

Full mouth x-rays - once in any 36 consecutive months

80%

80%

80%

Major Services

Year 1

Year 2

Year 3+

Endodontics: root cancal filling and pulpal therapy

10%

25%

50%

Complex oral surgery

10%

25%

50%

Periodontics: treatment for diseases of gums and bone supporting the teeth

10%

25%

50%

Surgical extractions

10%

25%

50%

Crowns, Bridges, Dentures, once in five years

10%

25%

50%

General anesthesia for covered surgical procedures

10%

25%

50%

Orthodontic care for dependent children to age 19 (care started after 1/1/04) Lifetime maximum is $1,500

none

none

50%

The annual deductible amount is $50 per person per year (waived for services that are covered 100%).

The benefit maximum is $1,000 per person per year.

Dependent age limit is 19 or 25 for full-time student. Proof of student status is required.

2013 & 2012 Delta Dental Plan B Summary