| Benefit Period Deductible (Per Covered Person) |
$50
|
$100
|
| Oral Exams - Two per Benefit Period |
Covered 100%
|
Covered 80%
|
| Bite Wing X-rays -- Two per Benefit Period
|
| Prophylaxis (Cleaning) -- Two per Benefit
Period |
| Fluoride Treatment - One treatment per benefit
period, limited to dependents up to age 19 |
| Space Maintainers - Limited to eligible dependents
up to Age 19 |
| Emergency Palliative Treatment - Includes
Emergency oral exam |
| Fillings |
80% After Deductible
|
60% After Deductible
|
Benefit Period - Jan. 1 - Dec.
31; Dependent Age Limit - 23, Removal at end of month;
Benefit Period Max. (Per Member) - $1,000. (Policy contains
complete benefits & exclusions.) |
