DENTAL LIMITATIONS 

The following services will be subject to limitations as set forth below:   

1. Full mouth x-rays - one every five years.

2. One set(s) of bitewing x-rays per six months through age thirteen, and one set(s) of bitewing x-rays per  twelve months for age fourteen and older.

3. Periodic oral evaluation - one per six months.

4. Limited oral evaluation (problem focused) -  limited to one per dentist per twelve months.

5. Prophylaxis - one per six months.

6. Fluoride treatment - one per six months through age eighteen.

7. Space maintainers - only eligible for Members through age eighteen when used to maintain space as a result of prematurely lost deciduous molars and permanent first  molars, or deciduous molars and permanent first molars that have not, or will not develop.

8. Prefabricated stainless steel crowns - one per  tooth per  lifetime for age fourteen years and  younger.

9. Crown lengthening - one per tooth per lifetime.

10. Periodontal maintenance following active periodontal therapy - two per twelve months in addition to routine prophylaxis.

11. Periodontal scaling and root planing - per two year period per area of the mouth.

12. Placement or replacement of single crowns, inlays, onlays,  single and abutment buildups and post and cores, bridges, full and partial dentures -  one within five years of their placement.

13. Denture relining, rebasing or adjustments - are  included in the denture charges if provided within six months of insertion by the same dentist.

14. Subsequent denture relining or rebasing - limited to one  every three year(s) thereafter.

15. Surgical periodontal procedures - one per two year period per area of the mouth.

16. Sealants - one per tooth per three year(s) through age fifteen on permanent first and second molars.

17. Pulpal therapy - through age five on primary  anterior teeth  and through age eleven on primary posterior molars.

18. Root canal treatment and retreatment - one per tooth per lifetime.

19. Recementations by the same dentist who initially inserted the crown or bridge during the first  twelve months are included in the crown or bridge benefit, then one per twelve months thereafter; one per twelve months for other than the dentist who initially inserted the crown or bridge.

20. Replacement restorations - limited to one per twelve months.

21. Contiguous surface posterior restorations not  involving the occlusal surface will be payable as one surface restoration.

22. Posts are only covered as part of a post buildup.

23. An Alternate Benefit Provision (ABP) will be applied if a dental condition can be treated by means of a professionally acceptable procedure which is less costly  than the treatment  recommended by the dentist.  The ABP does not commit the member to the less costly treatment.  However, if the member and the dentist choose the more expensive treatment, the member is responsible for the additional charges beyond those allowed for the ABP.

24. Payment for orthodontic services shall cease at the end of the month after termination by the Company.