Page 9 - Allegacy 2019 Benefit Guide Full Time

Voluntary Dental Benefits
Type A: Preventive Services
Type B: Basic Services
Type C: Major Services
UCR (Usual Customary Reasonable)
Plan Year Deductible (Applies to
Type B & C)
Plan Year Maximum
8 |
Benefit Features
100% Covered
 Routine exams (2 per 12 months)*
 Routine Cleaning (2 per 12 months)
 Bitewing X-ray (max 4 films; 1 per 12 months
 Fluoride to age 16 (1 per 12 months)
 Adjunctive Pre-Diagnostic Oral Cancer Screening (1 per 12
months for age 40+)
80% Covered
 Fillings (benefit allowed for amalgam restorations on
posterior teeth)
 Periodontal Maintenance (2 per 12 months in addition to
routine cleaning)
 Full Mouth X-ray (1 per 24 months)
 Emergency Pain Treatment (1 per 12 months)
 Simple Extractions
 Repair of Crown, Denture or Bridge
 Sealants to age 16 (permanent molars, 1 per 36 months)
50% Covered
 Anesthesia (subject to review, covered with complex oral
surgery)
 Oral Surgery (surgical extractions & impactions)
 Endodontics (root canals)
 Non-surgical Periodontics
 Surgical periodontics (gum treatments)
 Space maintainers to age 16 (1 per 24 months)
 Inlays and Onlays
 Crowns, Bridges, Dentures & Endostea Implants (in lieu of an
approved 3-unit bridge)
90th
$50 per Individual
Maximum 3 per Family (or $150)
$1,250