Maximum annual benefit of $1,000 per person.

Annual maximum applies to Basic and Major Service Benefits only.

 Diagnostic and Preventive Service Benefits

 Paid at 100% of MAC*

• Semi-annual cleaning, polishing, and examination 
• Annual bitewing x-rays
• Complete x-ray series (every five years)
• Fluoride treatment (under age 12)
• Sealant: Once per lifetime (primary molars through age 10; secondary molars through age 15)
• Emergency treatment:  Palliative (to alleviate pain), not restorative

 Basic Service Benefits

 Paid at 80% of MAC*

• Inpatient consultation
• Anesthetics:  Novocain, IV sedation, general
• Basic restoration:  Amalgam and composite fillings
• Non-surgical periodontics
• Endodontics
• Oral surgery
• Simple extraction
• Repair of crowns, inlays, onlays, bridges, and dentures

 Major Service Benefits

 Paid at 50% of MAC*

• Surgical periodontics
• Inlays, onlays, crowns
• Prosthetics: Dentures and bridges, no implants

 Orthodontics (under age 19)

 Paid at 50% of MAC*

• Orthodontic lifetime benefit maximum of $1,000 per person

*MAC:  Maximum Allowable Charge — The negotiated charge the plan pays to providers.