Selected Covered Services and Frequency Limitations*
Low Plan
How Many/How Often:
Type A - Preventive
Oral Examinations Full Mouth X-rays
2 in a year
1 in 36 months 1 in 12 months
Bitewing X-rays (Adult/Child)
Prophylaxis - Cleanings
2 in a year
Topical Fluoride Applications
1 in 12 months - Children to age 19
Type B - Basic Restorative
How Many/How Often:
Sealants Space Maintainers Amalgam and Composite Fillings Endodontics Root Canal Periodontal Surgery Periodontal Scaling & Root Planing Periodontal Maintenance Oral Surgery (Simple Extractions) Oral Surgery (Surgical Extractions) Other Oral Surgery Emergency Palliative Treatment General Anesthesia
1 in 36 months - Children to age 16 1 per lifetime per tooth area - Children up to age 19 1 in 24 months. 1 per tooth per lifetime
1 in 36 months per quadrant 1 in 36 months per quadrant 2 in 1 year, includes 2 cleanings
Type C - Major Restorative
How Many/How Often:
TYPE C SERVICES ARE NOT COVERED WITH THIS COVERAGE TYPE.
*Alternate Benefits: Where two or more professionally acceptable dental treatments for a dental condition exist, reimbursement is based on the least costly treatment alternative. If you and your dentist have agreed on a treatment that is more costly than the treatment upon which the plan benefit is based, you will be responsible for any additional payment responsibility. To avoid any misunderstandings, we suggest you discuss treatment options with your dentist before services are rendered, and obtain a pretreatment estimate of benefits prior to receiving certain high cost services such as crowns, bridges or dentures. You and your dentist will each receive an Explanation of Benefits (EOB) outlining the services provided, your plan’s reimbursement for those services, and your out-of-pocket expense. Actual payments may vary from the pretreatment estimate depending upon annual maximums, plan frequency limits, deductibles and other limits applicable at time of payment. The service categories and plan limitations shown above represent an overview of your Plan of Benefits. This document presents many services within each category, but is not a complete description of the Plan. Please see your Plan description/Insurance certificate for complete details. In the event of a conflict with this summary, the terms of your insurance certificate will govern.
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DN-GCERT-GOLD Multioption Dental Benefit Summary
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