Dental Benefits

Calendar Year Deductible (Individual/Family)

$50/$150

$50/$150

$50/$150

Calendar Year Maximum Per Person

$1,500+ MAXAdvantage

$1,500+ MAXAdvantage

$1,500+ MAXAdvantage

Diagnostic and Preventive
Oral exams (all types) twice per calendar year

Bitewing and Periapical x-rays as needed

Full-mouth x-rays once in any 36 consecutive months

Cleanings (all types) twice per calendar year

Fluoride, once per calendar year for dependents under the
age 19

Emergency palliative treatment

Space maintainers, once in 5 years to age 16

100%

100%

100%

Basic
Fillings, including composite fillings on all teeth

Periodontics: treatment for diseases of gums and bone
supporting the teeth

Endodontics: root canal filling and pulpal therapy

Sealants for dependent children under 19, once per tooth
every 5 years, limited to non-decayed first and second
permanent molars

Simple and surgical extractions

90%

80%

80%

Major
Oral surgery, except for extractions covered under Basic

Prosthetics: bridges and dentures; replacement will be
covered only once in 5 years, but not during the first 12
months of coverage

Crowns, jackets, labial veneers, inlays and onlays when
required for restorative purposed, once in 5 years

60%

50%

50%

Orthodontics
(For dependent children to age 19 who begin treatment while
covered by this plan)

50%

50%

50%

Orthodontic Lifetime Maximum
(per eligible dependent child)

$1,500

$1,500

$1,500

MAXAdvantage - Claims paid for exams, cleanings, x-rays and fluoride treatment do not apply to your calendar year benefit maximum.