Basic Plan


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The Basic Plan provides benefits for diagnostic, preventive & basic care eligible charges.

Deductible

Preventive/Diagnostic

Basic Services

Major Services

Annual Benefit Maximum

$50 Per Person/$150 Per Family

100% (Not subject to deductible)

80% (After deductible)

Not Covered

$750 Per Person

Preventive Services

  • Routine Dental Examinations
    Twice per calendar year

  • Cleaning
    Twice per calendar year

  • Topical fluoride application for
    children under age 19
    Twice per calendar year

  • Total mouth x-ray
    Once every 36 months

  • Bitewing x-rays
    Twice per calendar year

Basic Services

  • Restorations (fillings)
    Amalgam, silicate cement, acrylic and composite

  • Oral Surgery
    Extractions (uncomplicated surgical removal of an erupted tooth), incision/drainage of abscess, cyst or tumor removal

  • General anesthesia and postoperative care

  • Periodontics
    Root planning/scaling, gingivectomy/gingivoplasty

  • Endodontics
    Root canals (including necessary x-rays/cultures, excluding final restoration)



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