Dental Summary of Benefits: Administrative

ODS Dental Plan

Plan Type: Fee for Service	Coverage
Deductible	$50.00
Annual Maximum	$1,500.00
Preventive Care
Oral Examinations Prophylaxis Topical Fluoride Application (18 and under/high risk) Space Maintainers Sealants Bitewing X-rays (once every 6 months) Full mouth X-rays (once every 3 years)	100% Deductible waived
Restorative Services
Extractions Fillings (posterior teeth paid to amalgam fee) Palliative Emergency Treatment Oral Surgery (surgical extractions & certain minor surgical procedures) Endodontics Periodontic Services Inlays (amalgam reimbursement fee) Brush Biopsy (once in 6 month period)	80%
Major Dental Care
Onlays Crowns	80%
Prosthodontic Services
Implants Bridges Dentures Partial Dentures Prosthodontics	50%
Oral Health Total Health
Diabetics eligible for additional prophylaxis (cleanings) –requires proof of condition from provider Pregnant women eligible for additional prophylaxis (cleanings) in third trimester	100% Deductible waived
Orthodontia Coverage
Coverage	80%
Lifetime Maximum	$1,500.00

A complete list of exclusions and limitations can be found at ODS Dental Plan 4 Summary.