Highlights of the Plan


Features
How the plan works	You may visit any licensed dentist. The plan pays a percentage of covered services, based on usual and customary or reasonable rates (UCR)
Annual deductible	None
Maximum plan benefits	$1,750 per person per calendar year


Covered Services
Class I services: Preventive services, including: Cleaning two times per calendar year Fluoride application, age 14 and under, two times per calendar year Sealants, through age 18, once every five calendar years Space maintainers Diagnostic services, including: Routine exams, two times per calendar year Bitewing X-ray, two times per calendar year Full mouth X-rays or panoramic film, once every five years	Plan pays 100% of UCR
Class II services: Oral surgery, including surgical extractions, minor surgical procedures Restorative, including treatment of tooth decay with amalgam and synthetic porcelain Endodontic, including procedures for pulpal therapy, root canal filling Periodontic, including treatment of tissues supporting the teeth, scaling	Plan pays 80% of UCR
Class III services: Restorative, including crowns, jackets, gold or cast restorations, onlays and implants	Plan pays 80% of UCR
Class IV services: Prosthodontic, including bridges, partials, complete dentures	Plan pays 50% of UCR
Class V services (Substitute teachers are not eligible for this benefit): Orthodontics, including exams, X-rays, surgery, installation of appliance	Plan pays 50% of UCR up to a lifetime maximum benefit of $1,250 per person