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| Class I — Preventive services | |
|---|---|
| Oral exams, bitewing X-rays, teeth cleanings and fluoride | Covered — 75% twice per calendar year (90-day benefit waiting period applies). |
| Class II — Restorative services | |
| Replacement fillings and onlays, crowns, extractions and root canal therapy |
Covered — 50% of the approved amount; subject to frequency limitations (90 day benefit waiting period applies) |
| Benefit maximum | |
| The benefit maximum limits the amount payable for services each calendar year. Once a member reaches the benefit maximum, services will not be paid for that member for the balance of the calendar year. We will continue to pay claims for other eligible members until each member has reached the maximum. | $800 per member, per calendar year |