COVERED DENTAL SERVICES. See Section 3 for additional benefit limits and coverage information. Network Dentists Non-network Dentists Major Restorative Services Crowns & Onlays* Under age 19 75% - After deductible 75% - After deductible Age 19 and older Not Covered Not Covered Oral surgery services* Under age 19 75% - After deductible 75% - After deductible Age 19 and older 40% - After 12 month waiting period 40% - After 12 month waiting period General anesthesia or IV sedation – in a dental office* Under age 19 75% - After deductible 75% - After deductible Age 19 and older 40% - After 12 month waiting period 40% - After 12 month waiting period Surgical periodontal services* Under age 19 75% - After deductible 75% - After deductible Age 19 and older Not Covered Not Covered Prosthodontics Bridges and dentures* Under age 19 75% - After deductible 75% - After deductible Age 19 and older Not Covered Not Covered Implants Under age 19 75% - After deductible 75% - After deductible Age 19 and older - Coverage is for single tooth implant only; all other implants are not covered. Not Covered Not Covered Occlusal (night) guards Occlusal (night) guards* Under age 19 50% 50% Age 19 and older 50% 50% Orthodontics Medically necessary orthodontic services (braces)* Under age 19 50% - After deductible 50% - After deductible Age 19 and older Not Covered Not Covered
COVERED DENTAL SERVICES. This section describes covered dental services. This plan covers services only if they meet all of the following requirements: • listed as a covered dental service in this section. The fact that a dentist has prescribed or recommended a service, or that it is the only available treatment for an illness or injury does not mean it is a covered dental service under this plan. • dentally necessary services or medically necessary orthodontics, consistent with our dental policies and related guidelines at the time the services are provided. • not listed in Exclusions section. • received while a member is enrolled in the plan. • consistent with applicable state or federal law. We review dental necessity in accordance with our dental policies and related guidelines. Our dental policies can be found on our website. This plan only covers dental services that are dentally necessary or orthodontics which we determine are medically necessary. To help ensure that you and your dentist understand your benefits before the service is rendered, we recommend that you obtain a predetermination. A predetermination will provide your dentist with a coverage estimate for the services requested. We recommend that you or your dentist request a predetermination for the covered dental services in the Summary of Benefits marked with a (*). This plan does not apply pre-existing condition exclusions.
COVERED DENTAL SERVICES. We cover the following services when rendered by a dentist (See Section 8.0 - Glossary for definition of dentist). All covered dental services are subject to the provisions below. This agreement covers multi-stage procedures which have a start date before the effective date of this agreement if: • the multi-stage procedures have a completion date after the effective date of this agreement; and • the multi-stage procedures are covered dental services under this agreement. Subject to any calendar year or other maximums, we will pay up to our allowance less any benefits paid or payable under any previous plan for multi-stage procedures.
COVERED DENTAL SERVICES. Pediatric dental benefits will be provided through the Dental Plan for Members up to the end of the Calendar Year in which the Member turns age 19 in accordance with the Maryland Children’s Health Insurance Plan dental benefits, which includes benefits for periodic screening in accordance with the periodicity schedule developed by the American Academy of Pediatric Dentistry and as specified in the Schedule of Benefits.
COVERED DENTAL SERVICES. Subject to the Exclusions, Limitations, and conditions of the Plan, a Covered Person is entitled to Benefits for the following Covered Services in the amounts specified in the Schedule of Benefits.
COVERED DENTAL SERVICES. Subject to the limitations and exclusions included in this Contract, the Completed dental Services are Benefits when provided by a Provider (or other person legally permitted to perform such Services by authority of license) and are determined under the standards of generally accepted dental practice to be Necessary and appropriate. Benefits will be determined based on the terms of this Contract and Delta Dental’s Processing Policies.
COVERED DENTAL SERVICES. The Annual Benefit Maximum is $1000 for all services. Please refer to the Covered Services section of the Schedule of Dental Benefits for a more complete explanation of the specific services covered. All Covered Services are subject to the conditions, exclusions, limitations, terms and provisions of your Plan, including any attachments or riders. The following list includes Covered Dental Services and the Maximum Allowed Amount Alliant will reimburse for these services. Preventive Allowed Amount D0120 PERIODIC ORAL EVALUATION ESTABLISHED PATIENT $65.91 D0150 COMPREHENSIVE ORAL EVALUATION - NEW/ESTABLISHED PATIENT $116.00 D0140 LIMITED ORAL EVALUATION - PROBLEM FOCUS $110.00 D0145 ORAL EVALUATION PATIENT< 3 YEARS OF AGE AND COUNSELING WITH PRIMARY CAREGIVER $105.64 D0160 DETAILED & EXTENSIVE ORAL EVALUATION - PROBLEM FOCUS REPORT $234.75 D0170 RE-EVALUATION - LIMITED PROBLEM FOCUSED $81.26 D0180 COMPREHENSIVE PERIODONTAL EVALUATION - NEW/ESTABLISHED PATIENT $130.01 D0210 INTRAORAL-COMPLETE SERIES RADIOGRAPH IMAGES $185.00 D0270 BITEWING - SINGLE RADIOGRAPHC IMAGE $38.00 D0272 BITEWINGS - TWO RADIOGRAPHIC IMAGES $61.00 D0273 BITEWINGS-THREE RADIOGRAPHIC IMAGES $74.00 D0274 BITEWINGS - FOUR RADIOGRAPHC IMAGES $85.00 D0277 VERTICAL BITEWNGS - 7-8 RADIOGRAPH IMAGES $92.13 D0330 PANORAMIC RADIOGRAPHIC IMAGE $167.03 D1110 PROPHYLAXIS - ADULT $120.99 D1120 PROPHYLAXIS - CHILD $80.36 D1206 TOPICAL APPLICATION FLUORIDE VARNISH $76.74 D1208 TOPICAL APPLICATION OF FLUORIDE $61.40 D1351 SEALANT - PER TOOTH $73.13 D1352 PREVENTIVE RESIN RESTORATION MODERATE/HIGH CARIES RISK $218.50 D2940 PROTECTIVE RESTORATION $361.15 D2990 RESIN FILL OF TOOH SURFACE $101.12 D1353 SEALANT REPAIR - PER TOOTH $51.47 D1510 SPACE MAINTAINER-FIXED UNILATERAL - PER QUADRANT $450.54 D1516 SPACE MAINTAINER-FIXED-BILATERAL MAXILLARY $648.27 D1517 SPACE MAINTAINER-FIXED BILATERAL MANDIBULAR $645.56 D1520 SPACE MAINTAINER - REMOVABLE UNILATERAL - PER QUADRANT $442.32 D1526 SPACE MAINTAINER- REMOVE-BILATERAL, MAXILLARY $684.38 D1527 SPACE MAINTAINER- REMOVE- BILATERAL, MANDIBULAR $684.38 D1575 DISTAL SHOE SPACE MAINTAINER - FIXED UNILATERAL-QUADRANT $500.20 D1551 RE-CEMENT/RE-BOND BILATERAL SPACE MAINTAINER-MAXILLARY $100.22 D1552 RE-CEMENT/RE-BOND BILATERAL SPACE MAINTAINER - MANDIBULAR $99.32 D1553 RE-CEMENT/RE-BOND UNILATERAL SPACE MAINTAINER-QUADRANT $99.32 D1556 REMOVAL OF UNILATERAL SPACE MAINTAINER - PER QUADRANT $82.16 D1557 REMOVAL FIXED BILATERAL SPACE MAINTAINER - MAXILLARY $82.16 D1558 ...
COVERED DENTAL SERVICES. Charges up to the Benefit Maximum for: first installation, including adjustments of partial, permanent or full temporary or permanent removable dentures to replace or more natural teeth extracted while the person is insured; denture adjustments that occur more than 3 months after installation; replacement of an existing partial or full removable dentures, if it; was installed at least 5 years before and cannot be made serviceable; or is a temporary full denture which replaces one or more natural teeth extracted while the person is insured and for which replacement by a permanent denture is required and takes place within one year from the date the temporary denture was installed; and addition of teeth to an existing partial denture, if required to replace one or more natural teeth extracted while the person is insured.
COVERED DENTAL SERVICES. We cover the following services when rendered by a dentist (See Section 8.0 - Glossary for definition of dentist). All covered dental services are subject to the provisions below. If a service or category of service is not specifically listed as covered, it is not covered under this agreement. Only services that we have reviewed and determined are eligible for coverage under this agreement are covered. All other services are not covered. This agreement covers multi-stage procedures which have a start date before the effective date of this agreement if: the multi-stage procedures have a completion date after the effective date of this agreement; and the multi-stage procedures are covered dental services under this agreement. Subject to any calendar year or other maximums, we will pay up to our allowance less any benefits paid or payable under any previous plan for multi-stage procedures. Pediatric Dental Care Services In accordance with PPACA, this agreement provides coverage for the dentally necessary services listed in the Summary of Dental Benefits for an enrolled child under the age of nineteen (19), when rendered by a network dentist or non-network dentist. The coverage for dental care services rendered to an enrolled child will end for the child on the first day of the month following their 19th birthday, unless otherwise specified in the Summary of Medical Benefits. If a covered dental care service is rendered more than our contractually specified treatment time or age limitations, which are based on our dental policies and related guidelines, it is not covered.
COVERED DENTAL SERVICES. The benefit covers the dental services when they are performed by a licensed dentist and when they are determined necessary and customary in accordance with standards of accepted dental practice. EXHIBIT C PENSION AGREEMENT This Pension Agreement is made with the understanding that it will become effective as of August 7, 2000 except as may be specifically otherwise provided herein. It will be considered a part of the Labor Agreement and shall remain in effect until the termination of the Labor Agreement. The Parties agree that the provisions of Section 2, Membership; Section 4, Benefits; and Section 5, Form of Benefit Payment, of the Pension Plan approved by the Internal Revenue Service shall become a part of this Agreement with the following revisions:
