80% 20% 80% 20% Class IV: Orthodontia After Deductible After Deductible After Deductible After Deductible Coverage for Dependent Children to age 19 $2,400 $2,400 Lifetime Maximum Study Models or Diagnostic Casts - Payable only when in conjunction with orthodontic workup 90% 10% 80% 20% Class VI: Periodontal After Deductible After Deductible After Deductible After Deductible Gingivectomy Gingivioplasty Alveoplasty Vestibuloplasty Osseous Surgery No Annual or Lifetime Maximums apply 90% 10% 80% 20% Class VII: Oral Surgery After Deductible After Deductible After Deductible After Deductible Surgical Extractions of Impacted Teeth No Annual or Lifetime Maximums apply 90% 10% 80% 20% Class IX: Surgical Implants After Deductible After Deductible After Deductible After Deductible No Annual or Lifetime Maximums apply
Class IV: Orthodontia Coverage for Dependent Children to age 19 Lifetime Maximum Study Models or Diagnostic Casts - Payable only when in conjunction with orthodontic workup 80% After Deductible $2,400 20% After Deductible 80% After Deductible $2,400 20% After Deductible Class VI: Periodontal Gingivectomy Gingivioplasty Alveoplasty Vestibuloplasty Osseous Surgery No Annual or Lifetime Maximums apply 90% After Deductible 10% After Deductible 80% After Deductible 20% After Deductible Class VII: Oral Surgery Surgical Extractions of Impacted Teeth No Annual or Lifetime Maximums apply 90% After Deductible 10% After Deductible 80% After Deductible 20% After Deductible Class IX: Surgical Implants No Annual or Lifetime Maximums apply 90% After Deductible 10% After Deductible 80% After Deductible 20% After Deductible
G00074.docx