Summary of Benefits

Alliance Chamber Health Insurance Program - Plan R

 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 - up to $25

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

 ORTHODONTICS - 0%

ANNUAL NON-ORTHODONTIC MAXIMUM - $1200

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

 **Will not duplicate surgical/medical benefits of a plan sponsored
    by the same employer.