Summary of Benefits for Plan 2

Restorative Care

 DIAGNOSTIC - 100%

• Oral Examinations
• Office Visits
• Diagnostic Casts
• Dental X-Rays
• Professional Consultation

 PREVENTIVE - 100%

• Plaque Control, Oral Hygiene Instructions
• Prophylaxis (Cleaning; Once in a Six-Month Period)
• Preventive Dental Hygiene
• Topical Applications of Fluoride (Up to Age 14)
• Sealants (Up to Age 14 on Permanent Molars Only)

 RESTORATIVE - 100%

• Amalgam Restorations (for Treatment of Cavities)
• Composite Restorations on Anterior Teeth
• Composite Restorations on Posterior Teeth (for Treatment of Cavities)*
• Pin Retention
• Space Maintainers to replace prematurely lost teeth
• Local Anesthesia

 OUT-OF-AREA EMERGENCY

• Services provided by a non-participating DDS out of geographic service area - up to $25

 ANNUAL NON-ORTHODONTIC MAXIMUM - $1200

 *Benefit applied at 100% of the amalgam fee for same restoration. 
  Patient is responsible for the difference.