Download AWANE DENTAL PLAN

AWANE DENTAL PLAN
Dental Benefits are Divided into Four Categories:
Type I - Preventative and Diagnostic
Type II - Basic Restorative
Type III - Major Restorative
Type IV – Orthodontics (if elected)
Preventative & Diagnostic - Paid at 100%
- Oral exams & cleanings (once every 6 months
with a $90 maximum each visit)
- Full mouth x-rays (once every 36 months)
- Bitewing, Occlusal, & Extraoral
x-rays (once every 12 months)
- Study models & casts (once every 3 years)
- Fluoride treatments (under age 19 once
every 12 months)
- Space maintainers (under age 19)
- Sealants (under age 15)
Basic Restorative - Paid at 80%
- Fillings: amalgam (metal) and composite (white)
- Periodontal prophylaxis (once every 6 months)
- Periodontal scaling & root planing (once per
quadrant every 2 years)
- Periodontal maintenance following active
treatment (every 3 months)
- Therapeutic pulpotomy
Major Restorative - Paid at 70%
- Complete or partial dentures
- Fixed bridges
- Crowns, Inlays and Onlays (when teeth cannot
be restored with regular fillings)
- Periodontal surgical services (gingivectomy,
gingivoplasty, osseous surgery, bone grafting
and tissues grafting)
- Implants (not cosmetic)
- Root canals (on permanent teeth)
- Oral surgery: extractions, biopsies,
excisions & incisions
- Recementing of crowns, inlays & onlays
(once every 12 months)
- Denture repair; rebase or reline of dentures
(once every 36 months)
Orthodontics (if elected) - Paid at 60%
For dependent children under age 19, $1,000
lifetime maximum benefit – also applied to
maximum annual benefit.
- Limited, interceptive and comprehensive
orthodontic treatments
- Appliance therapy (removable & fixed)
- Occlusal guards
¾ No claim forms or pre-estimates are necessary
¾ There is a maximum annual benefit of $1,500 per covered person
PLEASE NOTE:
Rates:
1) There is a three-month waiting period for major restorative benefits – WAIVED IF
PRIOR DENTAL COVERAGE IS PROVEN.
2) There is a nine-month waiting period for orthodontic benefits.
3) This summary does not describe all terms, conditions and limitations. Refer to
your Plan Document or contact your Benefits Manager for details.
Plan Type
Monthly Rate
Individual
$42.00
Two Person
$82.00
Family
$129.00
Effective January 1, 2007
Family with Orthodontic
$139.00