Low Option Dental Insurance Plan

• Annual maximum benefit for Types A and B for each Insured person is $1,000 per calendar year

• Type B deductible is $50

Type A : Diagnostic and Preventative Care

• 100% of usual, customary, and reasonable charges

• No Deductible

• No Waiting Period

• Clinical Oral Examinations – Maximum of 2 procedures per 12 months.

• Dental Prophylaxis – Maximum of 2 procedures per 12 months.

• Bitewing X-rays – Maximum of 1 set per 12 months, set includes up to 4 films.

• Fluoride Treatments – Limited to dependent children under the age of 16. Maximum of 1 procedure per 12 months.

• Sealants – Limited to dependent children under the age of 16. Maximum of 1 procedure per lifetime, applications made to permanent molar teeth only.

• Space Maintainers – Limited to dependent children under the age of 16 – for the premature loss of a primary tooth.

• Orthodontics does not appy

Type B: Basic Care

• 50% of usual, customary, and reasonable charges

• Subject to Deductible

• No Waiting Period

• Amalgam Restorations – Replacement of an existing only if in place for 24 months.

• Resin Restorations – Anterior - replacement of an existing only if in place for 24 months.

• Maintenance Prosthodontics – Adjustments and repairs to dentures and fixed bridges. Limited to adjustments and repairs performed more than 12 months after initial insertion.

• Emergency Care Treatment – Maximum of 1 procedure per 12 months.

• Full Mouth X-rays – including panoramic films – Maximum of 1 procedure in a 5 year period.

• Extractions (Simple) – Includes local anesthesia, suturing, if needed, and routine follow-up care.

• Orthodontics does not appy

Policies are underwritten by:

Citizens Security Life Insurance Company

High Option Dental Insurance Plan

• Annual maximum benefit for Types A-B-C for each insured person is $1,000 per calendar year

• Type B/C deductible is $50 per person with a maximum of 3 deductibles per family

• Type C care subject to a 12 month waiting period

Type A : Diagnostic and Preventative Care

• 100% of usual, customary and reasonable charges

• No Deductible

• No Waiting Period

• Clinical Oral Examinations – Maximum of 2 procedures per 12 months.

• Dental Prophylaxis – Maximum of 2 procedures per 12 months.

• Bitewing X-rays – Maximum of 1 set per 12 months, set includes up to 4 films.

• Fluoride Treatments – Limited to dependent children under the age of 16. Maximum of 1 procedure per 12 months.

• Sealants – Limited to dependent children under the age of 16. Maximum of 1 procedure per lifetime, applications made to permanent molar teeth only.

• Space Maintainers – Limited to dependent children under the age of 16 – for the premature loss of a primary tooth.

• Orthodontics does not appy

Type B: Basic Care

• 80% of usual, customary and reasonable charges

• Subject to Deductible

• No Waiting Period

• Amalgam Restorations – Replacement of an existing only if in place for 24 months.

• Resin Restorations – Anterior - replacement of an existing only if in place for 24 months.

• Maintenance Prosthodontics – Adjustments and repairs to dentures and fixed bridges. Limited to adjustments and repairs performed more than 12 months after initial insertion.

• Emergency Care Treatment – Maximum of 1 procedure per 12 months.

• Full Mouth X-rays – including panoramic films – Maximum of 1 procedure in a 5 year period.

• Extractions (Simple) – Includes local anesthesia, suturing, if needed, and routine follow-up care.

• Orthodontics does not appy

Type C: Major Restorative

• 50% of usual, customary, and reasonable charges

• Subject to Deductible

• Twelve Month Waiting Period

• Crowns Gold Inlays and Onlays – Benefits are provided only when the tooth, as the result of extensive decay or accidental injury, cannot be restored with a direct placement restoration. Maximum of 1 procedure in a 7 year period. Benefits will be based on the benefit for the corresponding non-cosmetic restoration.

• Prosthodontics – Complete or partial dentures, replacements limited to more than 5 years after prior placement. Bridge, pontics, and abutment crowns, replacements limited to more than 7 years after the initial placement.

• Extractions (Surgical) – Includes impactions, residual roots, and unerupted teeth.

• Endodontics – Pulpotomy – limited to dependent children under age 14; apicoectomy – Maximum of 1 procedure per lifetime; retrograde fillings – Maximum of 1 procedure per lifetime; root canal therapy – Maximum of 1 procedure per 24 months.

• Periodontics – Adjunctive Services – Scaling and root planning, 1 procedure per 24 months, per quadrant. Periodontal prophylaxis, limited to two prophylaxis procedures in a 12-month period.

• Periodontics – Surgical Services – Maximum of 1 procedure per 36 months, per quadrant.

• Oral Surgery – Includes pre-operative and post-operative care.

• Anesthesia – Only in conjunction with eligible complex oral surgery procedures and subject to review.

• Orthodontics does not appy