Dental

Dental Care* 

Insurer: Self-Insured
Policy #: 9000 

Benefits:

• Basic: 80%
• Major: 80%
• Basic & Major Combined Maximum: $2500 / yr per member and eligible dependents
• Orthodontia 50% Lifetime maximum $2500 for dependent children only

Basic coverage includes preventative and restorative services such as:

• oral examinations
• dental x-rays
• teeth cleaning
• topical application of fluoride and other anticariogenic substances
• treatment of periodontal and other diseases of the gums and mouth tissues
• application of pit and fissure sealant
• initial provision & replacement of amalgam, silicate, acrylic or composite restoration
• endodontic treatment, including root canal therapy
• relining, or rebasing dentures, or adjustments to dentures if a 6-month period has elapsed since the date the dentures were provided

Major coverage includes major restorative services such as:

• initial provision of crowns (other than stainless steel crowns) or gold inlays
• replacement of crown (other than stainless steel crowns)
• initial installation of full dentures, or partial dentures if required to replace natural tooth/teeth that were extracted after the effective date of the member’s coverage
• addition of teeth to existing dentures
• addition of teeth to fixed bridgework.

*An employee can waive these benefits if that individual provides proof that they have a comparable benefits through their spouse’s plan. If no proof is provided all benefits will be considered mandatory.