Page 10 - 2013-14 AAACU Benefits & Notices

Alpena Alcona Area CU 2013-14

Dental Coverage

Alpena Alcona Area CU Delta Dental PPO Plan
Member’s Responsibility (copays and dollar maximums)
Copays
- Class I – Preventive & Diagnostic services None
- Class II – Basic Restorative services 50% of approved amount
- Class III – Major Restorative services 50% of approved amount
- Class IV – Orthodontic services Not Covered
Dollar Maximums
- Annual Maximum (for Class I, II and III services) $1,000 per member
- Lifetime Maximum (for Class IV services) n/a
Class I Services
Oral Exams 100% of approved amount, twice a calendar year
A set (up to 4 films) of bitewing x-rays
- For members age 15 and younger 100% of approved amount, one in a calendar year
- For members age 16 and older 100% of approved amount, one in a calendar year
Panoramic or full-mouth x-rays 100% of approved amount, one every 60 months
100% of approved amount, any combination of 6 individual or sets of
Diagnostic x-rays
films each calendar year
Dental prophylaxis (teeth cleaning) 100% of approved amount, twice a calendar year
Brush Biopsy – to detect oral cancer 100% of approved amount one in a calendar year
Palliative (emergency) treatment 100% of approved amount
Fluoride treatment – for members age 19 and younger 100% of approved amount, twice a calendar year
Space maintainers – missing posterior (back) primary teeth – 100% of approved amount, once per quadrant per lifetime
for members age 16 and younger
Class II Services
Fillings – permanent teeth 50% of approved amount
Fillings – primary (baby) teeth 50% of approved amount
Recementation of crowns, veneers, inlays, onlays & bridges 50% of approved amount,
Oral surgery including extractions 50% of approved amount
Root canal treatment – permanent tooth 50% of approved amount
Scaling and root planing 50% of approved amount
Limited occlusal adjustments 50% of approved amount
Occlusal biteguards 50% of approved amount
General anesthesia or IV sedation 50% of approved amount
Repairs and adjustments of a partial or complete denture 50% of approved amount
Relining or rebasing of a partial or complete denture 50% of approved amount
Tissue conditioning 50% of approved amount
Periodontic maintenance 50% of approved amount
Class III Services
Onlays, crowns and veneer restorations – permanent teeth –
50% of approved amount
for members age 12 and older
Removal dentures (complete or partial) 50% of approved amount
Bridges (fixed partial dentures) – for members age 16 and older 50% of approved amount
Endosteal implants – for members age 16 and older who are
50% of approved amount, once per tooth in a 60 month period
covered at the time of the actual implant placement
Class IV Services – Orthodontic services for dependents under age 19
Minor treatment of tooth guidance appliances Not covered
Minor treatment to control harmful habits Not covered
Interceptive and comprehensive orthodontic treatment Not covered
Post-treatment stabilization Not covered
Cephalometric film (skull) and diagnostic photos Not covered

THIS BENEFIT SUMMARY IS A BRIEF DESCRIPTION OF COMMON SERVICES. CHECK DENTAL CERTIFICATE FOR ALL SERVICES,
FREQUENCY OF SERVICES AND CLASSIFICATION OF SERVICES.

Salus Group © Copyright 2013 Page | 10