Plan provisions

The plan provisions chart below should be used as a general guide only. Please refer to the Dental II coverage manual (pdf) for further information. If the information in this summary chart differs from the coverage manual, the Dental II coverage manual document will govern. 

Diagnostic and Preventive Maintenance Care

Benefits include:

A benefit period is the same as a calendar year. It begins on the day your coverage goes into effect and starts over each January 1. 

• Routine examination (2 in a benefit period)
• Teeth cleaning (2 in a benefit period)
• Diagnostic services
• Special preventive care for children
• X-rays

Routine and Restorative Care

Care includes:

• Regular cavity fillings
• Emergency treatment for relief of pain
• Routine oral surgery
• Anesthesia
• Extractions

Dental Prosthetics, Endodontic, Periodontal, and High Cost Restorations

Services include:

• Bridges, partial and complete dentures (Prosthetic)
• Crowns (High-cost restorations)
• Root Canals (Endodontic)
• Implants (Prosthetic)

Straighter Teeth (Orthodontic Care)

Straighter teeth care includes:

• Treatment necessary for the proper alignment of teeth
• Orthodontic benefits are paid quarterly

Benefit Period Maximum or Annual Maximum

The Benefit Period or Annual Maximum is the maximum benefit each covered person is eligible to receive for certain covered services in a Benefit Period. The Benefit Period Maximum is a combined maximum for PPO, Premiere, and Non-Participating providers. 

The Dental II Maximum is $2,000 per member per benefit period. 

Annual Maximum Carryover (To Go)

Eligible members may carry over any qualified, unused portion of their Annual Maximum benefit from the prior Benefit Period, subject to the following guidelines:

• The member must have been covered under the Dental II plan for the entire plan year or full benefit period (Jan. 1 - Dec. 31) immediately preceding the current Benefit Period, with coverage for major services. 
• The member must have submitted at least one claim during the Benefit Period that would apply to their Annual Maximum where the allowed dollar amounts are greater than zero dollars.
• The carried-over amount may not exceed the amount of the regular Annual Maximum, and the total combined Annual Maximum may not exceed twice the regular Annual Maximum. 
  • This means the member can carry over up to $2,000 to the next Benefit Period for up to $4,000 annual maximum if they meet the criteria above. 

Please note that if the policyholder changes, the deductible, benefit period maximum, and annual maximum carryover to go dollars all start over.