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1 Replacement is subject to a limitation requiring the existing restoration to be 5+ years old.
2 Base or noble metal is the benefit. If an inlay, onlay or indirectly fabricated post and core is made of high noble metal, an additional fee up to $100.00 per tooth will be charged for the upgrade.
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 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.
5 Replacement is subject to a limitation requiring the existing denture to be 5+ years old.
6 Limited to 1 per denture during any 12 consecutive months.
7 Replacement is subject to a limitation requiring the existing bridge to be 5+ years old.
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