PEDIATRIC BENEFITS. The dental benefits described in this Section are available only for Members under 21 years old. Members that were under 21 years old when they enrolled in this Benefit Plan, and during the Policy Year attain age 21, will continue to be covered under this Section until the end of that Policy Year. In accordance with federal law, We will provide benefits for all required pediatric dental services. Services will be subject to any duration and frequency limits and exclusions as identified in the federal benchmark plan. For the In-Network unlimited Dental Benefits, the Schedule of Dental Benefits will contain an Out of Pocket (OOP) Yearly Maximum per Child Member, and an Out of Pocket (OOP) Yearly Maximum per 2 or more Child Members. Each will apply depending on how many Child Members are covered under this Benefit Plan. If there is only one Child Member, the Out of Pocket (OOP) Yearly Maximum per Child Member will apply, which is the maximum dollar amount that the Child Member will have to pay out of his/her own pocket during a Policy Year. Once the Child Member pays the maximum OOP in deductible and coinsurance for covered Benefits, the Member’s Benefits will be 100% covered until the end of the Policy Year. To the contrary, if there are two or more Child Members covered under this Benefit Plan, the Out of Pocket (OOP) Yearly Maximum per 2 or more Child Members will apply. Once that maximum OOP amount is paid in deductible and coinsurance for covered Benefits by any Child Member, all the Child Members will be 100% covered until the end of the Policy Year. These OOP maximums are accumulated when the covered Benefits are received by the Child Member from Participating Providers. Any out of pocket amounts paid by Members for services received from Non- Participating Providers will not accrue to any of these OOP maximums. After any applicable Waiting Period, and after the Member’s payment of the corresponding deductible and coinsurance, according to the Schedule of Dental Benefits, this Contract will cover: Diagnostic and Preventive Services Oral Exams One periodic, limited problem-focused or comprehensive oral exam every 6 months. One detailed problem-focused oral evaluation every 12 months. Oral Cleanings (Prophylaxis) Limited to one every 6 months. One additional cleaning during the Policy Year will be allowed for Members that are under the care of a medical professional during pregnancy. Fluoride Treatment Limited to children under 20 years old; and Limit...
