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Dental Benefits Summary: The Flexible Choice Plan

Benefit Coverage
Calendar Year Deductible
  • None.
Calendar Year Maximum
  • In-Network: Plan pays up to $900 per person per calendar year toward all covered expenses.
  • Out-of-Network: Plan pays up to $750 per person per calendar toward all covered expenses.

Note: The calendar year maximum does not apply to pediatric oral care.

Preventive Care Services
  • Oral exams and routine cleanings: twice in a calendar year
  • Bitewing x-rays and fluoride applications for children under 19: once per calendar year
  • Sealants for dependent children: once every three consecutive calendar years
  • Full mouth x-rays: once every three consecutive calendar years
  • Brush biopsy to detect oral cancer
  • Emergency treatment to relieve pain
  • Cleanings following periodontal therapy
In- and Out-of-Network: Plan pays 100% of covered expenses, up to the reasonable and customary charge. There is no deductible.
Note: Dental coverage under the Flexible Choice Plan is for preventive care services only. There is no coverage for non-preventive services.