| Preventive Services | In-Network Coverage | Out-of-Network Coverage | Waiting Periods | 
| Routine oral examinations (limit 2 every calendar year) | 100% No Deductible
 | 100% After Deductible(No deductible in GA, KS, LA, MS, TX)
 | None   | 
| Limited oral evaluation (limit 1 every calendar year) | 
| Comprehensive oral evaluation (limit 1 every 3 years) | 
| Bitewing X-rays (1 set of films every calendar year for covered persons age 10 and younger and up to 4 films every calendar year for covered persons age 11 and older) | 
| Panoramic film combined with Full Mouth (limit 1 every 5 years, age 12 and up) | 
| Cleanings (limit 2 every calendar year) | 
| Topical fluoride treatment (limit 2 every calendar year) | 
| Sealants (limit of 1 per tooth per lifetime, age 14 and younger) | 
|  | 
| Basic Services | In-Network Coverage | Out-of-Network Coverage | Waiting Periods | 
| Palliative treatment of dental pain – per visit5 | 80% After Deductible
 | 80% After Deductible
 | Six-month waiting period applies – policyholders who provide proof of 12 months prior coverage may be exempt from this waiting period.1 | 
| Simple extractions and root removal | 
| Fillings (limit 1 per tooth, every 2 years, composite covered on front teeth only2) | 
| Space maintainers (age 14 and under, initial placement only. Age 19 and under in IL) | 
| Prefabricated stainless steel crowns | 
|  | 
| Major Services | In-network dentist | Out-of-network dentist | Waiting Periods | 
| Endodontics – Root canals (limit 1 per lifetime, per tooth) | 50% After Deductible
 | 50% After Deductible
 | Twelve-month waiting period applies – policyholders who provide proof of 12 months prior coverage may be exempt from this waiting period.1 Six month waiting period in Vermont | 
| Complete dentures (limit 1 every 5 years) | 
| Partial dentures (limit 1 every 5 years) | 
| Denture repair and adjustments | 
| Crowns (limit 1 per tooth every 5 years) | 
| Onlays and Inlays (limit 1 per tooth every 5 years) | 
| Surgical extractions | 
| Periodontal maintenance (limit 2 every year) – no waiting period for this service. | 
| Periodontal scaling and root planing (limit 1 per quadrant every 3 years) – no waiting period for this service. | 
|  | 
| Maximums and Deductible | 
| Maximum | Year 1: $1,250 Year 2: $1,500
 | 
| Deductible | $50 individual $150 family
 | 
| States Offered | AL, AR, AZ, CA, CT, CO, DC, DE, FL, GA, IA, ID, IL, IN, KS, KY, LA, MD, ME, MI, MN, MO, MS, NC, ND, NE, NH, NY, OH, OK, OR, PA, SD, TN, TX, UT, VA, VT, WI, WV, WY |