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	Dental

	Dental Care* Insurer: Self-Insured Policy #: 9000 Benefits: Basic: 80% Major: 80% Basic & Major Combined Maximum: $2500 / yr per member and eligible dependents Orthodontia 50% Lifetime maximum $2500 for dependent children only Basic coverage includes preventative and restorative services such as: oral examinations dental x-rays teeth cleaning topical application of fluoride and other anticariogenic substances treatment of periodontal and other diseases of the gums and mouth tissues application of pit and fissure sealant initial provision & replacement of amalgam, silicate, acrylic or composite restoration endodontic treatment, including root canal therapy relining, or rebasing dentures, or adjustments to dentures if a 6-month period has elapsed since the date the dentures were provided Major coverage includes major restorative services such as: initial provision of crowns (other than stainless steel crowns) or gold inlays replacement of crown (other than stainless steel crowns) initial installation of full dentures, or partial dentures if required to replace natural tooth/teeth that were extracted after the effective date of the member’s coverage addition of teeth to existing dentures addition of teeth to fixed bridgework. *An employee can waive these benefits if that individual provides proof that he/she has comparable benefits through their spouse’s plan. If no proof is provided all benefits will be considered mandatory.

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