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

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

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

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

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

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

Citizens Security Life Insurance Company