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.

Human Resources