Twice per calendar year
Routine cleanings
Once per calendar year
Bitewing X-rays
Once every 60 months
Full mouth X-rays
Once per calendar year (covered only for dependent children under age 14)
Fluoride
Basic Sealants
Covered only for dependent children under age 14; once per tooth each 36 months
Emergency exams Subject to routine exam frequency limit Periodontal maintenance If three months have passed since active surgical periodontal treatment; subject to routine cleaning frequency limit Fillings Replacement fillings every 24 months Composite (tooth colored) Covered on posterior teeth Simple endodontics Root canal therapy for anterior teeth Complex endodontics Root canal therapy for molar teeth
Non-surgical periodontics, including scaling and root planning
Once per quadrant per 24 months
Periodontal surgical procedures
Once per quadrant per 36 months
Harmfulhabit appliance Covered only for dependent children under age14
Major Oral surgery
Simple and complex
General anesthesia / IV sedation (covered only for specific procedures)
Covered only for specific procedures
Each 120 months per tooth if tooth cannot be restored by a filling
Crowns
Each 120 months per tooth
Core buildup
120 months old (initial placement / replacement)
Bridges
Dentures
60 months old (initial placement / replacement)
Additional benefits Scheduled / MAC design In and out-of-network claim payments are based on the amounts agreed to by network dentist, known as a negotiated fee schedule.
Insurance issued by Principal Life Insurance Company, 711 High Street, Des Moines, IA 50392 04052210597 - 6 Page 2 of 4
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