Page 11 - Allegacy 2019 Benefit Guide Part Time

Dental Benefits

Policy#D02703

You have an option to choose between two dental programs. The Core plan offers comprehensive coverage at an affordable cost while
the Buy Up plan includes a higher maximum benefit as well as adult & child orthodontia. The Buy Up plan bears a higher cost due to the

enhanced level of benefit.
Benefit Features Core Plan Buy Up Plan
100% Covered 100% Covered

 Routine exams (2 per 12 months)*
 Routine exams (2 per 12 months)*  Routine Cleaning (2 per 12 months)
 Routine Cleaning (2 per 12 months)  Bitewing X-ray (max 4 films; 1 per 12 months
Type A: Preventive  Bitewing X-ray (max 4 films; 1 per 12 months  Full Mouth X-ray (1 per 24 months)
Services  Fluoride to age 16 (1 per 12 months)  Fluoride to age 16 (1 per 12 months)
 Adjunctive Pre-Diagnostic Oral Cancer Screening  Adjunctive Pre-Diagnostic Oral Cancer Screening (1 per 12
(1 per 12 months for age 40+) months for age 40+)
 Sealants to age 16 (permanent molars, 1 per36 months)
 Space maintainers to age 16 (1 per 24 months)
80% Covered 90% Covered

 Fillings (benefit allowed for amalgam restorations  Emergency Pain Treatment (1 per 12 months)
on posterior teeth)  Fillings (Benefit allowed for amalgam restorations on
 Periodontal Mainenance (2 per 12 months in posterior teeth)
Type B: Basic Services addition to routine cleaning)  Simple Extractions
 Full Mouth X-ray (1 per 24 months)  Oral Surgery (surgical extractions & impactions)
 Emergency Pain Treatment (1 per 12 months)  Non-surgical Periodontics
 Simple Extractions  Endodontics (root canals)
 Repair of Crown, Denture or Bridge  Surgical periodontics (gum treatments)
 Sealants to age 16 (permanent molars, 1 per 36  Repair of Crown, Denture or Bridge
months)
50% Covered 50% Covered

 Anesthesia (subject to review, covered with  Anesthesia (subject to review, covered with complex oral
complex oral surgery) surgery)
 Oral Surgery (surgical extractions & impactions)  Inlays and Onlays
 Endodontics (root canals)  Crowns, Bridges, Dentures & Endosteal Implants (in lieu of
Type C: Major Services  Non-surgical Periodontics an approved 3-unit bridge)
 Surgical periodontics (gum treatments)
 Space maintainers to age 16 (1 per 24 months)
 Inlays and Onlays
 Crowns, Bridges, Dentures & Endosteal Implants
(in lieu of an approved 3-unit bridge)

50% Covered

 Adult & Dependent Child Coverage
Type D: Orthodontics Not Covered  Separate Lifetime Maximum of $2,500 per member
 Up to 25% of lifetime allowance may be payable on initial
banding

UCR (Usual Customary 90th 90th
Reasonable)
Plan Year Deductible $50 per Individual $50
(Applies to Type B & C) Maximum 3 per Family (or $150) Maximum 3 per Family (or $150)

Plan Year Maximum $1,250 $1,750

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