¹ Base or noble metal is the benefit. If an inlay, onlay or cast post and core is made of high noble metal, an additional fee up to $100.00 per tooth will be charged for the upgrade.

² Replacement is subject to a limitation requiring the existing restoration to be 5+ years old.

³ Porcelain and other tooth-colored materials on molars are considered a material upgrade with a maximum additional charge to the Enrollee of $150.00.

⁴ A benefit for permanent teeth only.

⁵ Replacement is subject to a limitation requiring the existing denture to be 5+ years old.

⁶ Includes after delivery adjustments and tissue conditioning, if needed, for the first six months after placement, if the Enrollee continues to be eligible and the service is provided at the Contract Dentist's facility where the denture was originally delivered.

⁷ Limited to 1 per denture during any 12 consecutive months.

⁸ Replacement is subject to a limitation requiring the existing bridge to be 5+ years old.

⁹ Listed Copayment covers up to 24 months of active orthodontic treatment excluding the services listed for D8999 (Start-up fee) and D8680 (Orthodontic retention). Beyond 24 months, an additional monthly fee not to exceed 75 percent of the Contract Orthodontist's Filed Fee applies.

¹⁰ In the event orthodontic treatment is not required or is declined by the Enrollee, a fee of $85.00 will apply. The Enrollee is also responsible for any incurred orthodontic diagnostic record fees.

¹¹ Includes adjustments and/or office visits up to 24 months. After 24 months, a monthly fee not to exceed 75 percent of the Contract Orthodontist's "filed fee" applies.