Page 10 - DataMax Benefits Enrollments Guide

Voluntary Dental Benefits

Policy# 01-D031247

Lincoln Financial Group Dental Benefits
100%
• Routine oral examinations (up to two per calendar year)
• Prophylaxis (routine cleanings- up to two per calendar year)
• Dental X-rays- bitewing films (up to one set per calendar year- including any
Type I- Diagnostic & Preventive taken as part of a full mouth series)
Services
• Fluoride treatments
• Sealants
• Emergency palliative treatment
• Sedative fillings
80%
• Dental X-rays- panoramic or full-mouth (one complete full mouth series, no
more than once every three years)
• Examinations (oral examinations, problem focused and/or emergency exams)
• Consultations
• Injection of antibiotics
Type II- Basic Services
• Fillings
• Prefabricated stainless steel or resin crowns
• Extractions and oral surgery
• Endodontics
• Periodontics (periodontal maintenance cleaning, non-surgical periodontal
services, periodontal surgery)
50%
• Space maintainers
• Extractions and oral surgery
• Administration of anesthesia
Type III- Major Services
• Repair of prosthetics
• Prosthodontics- fixed or removable
• Major restorations

Type II procedures: None
Waiting Periods
Type III procedures: 12 months
Late Entrant Waiting Periods Type II and Type III procedures: 12 months

th
Usual Customary Reasonable 90 percentile

Plan Year Deductible $100 lifetime per member, applies to Type II and Type III Services

$1,500
Plan Year Maximum
(all procedure types combined)

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