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Annual deductible (doesn't apply to diagnostic and preventive services, orthodontic services or accidental injuries)
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Annual maximum benefit (doesn't apply to orthodontic or TMJ services)
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Diagnostic and preventive services
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Exam and cleaning, twice/calendar year
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Periodontal cleaning and maintenance up to 4 times/calendar year (under certain oral health conditions)
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Complete X-rays every 3 years
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Supplementary bitewing X-rays, twice/calendar year
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70%–100% based on patient's incentive level (deductible doesn't apply)
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70%–100% based on patient's incentive level
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70%–85% based on patient's incentive level
50% occlusal guard (incentive levels don't apply). Your medical plan may provide additional coverage. (See " Medical Plans.")
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Major services—Prosthodontics
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70% (incentive levels don't apply)
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Orthodontic services for adults and children
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50% up to a $2,500 lifetime maximum (deductible, incentive levels and annual maximums don't apply)
Not more than $1,250 will be paid during the initial stage of treatment; the remaining plan benefit is paid seven months after the initial stage if the covered participant still meets eligibility requirements. (See " Medical Plans.")
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Temporomandibular joint (TMJ) disorders
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50% up to a $500 lifetime maximum for non-surgical treatment and appliances (deductible, incentive levels and annual maximums don't apply). Your medical plan may provide additional coverage. (See " Medical Plans.")
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100% for covered expenses incurred within 180 days of accident (deductible doesn't apply)
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