Savings You Can See
Monthly Payroll Deduction Effective: 7-1-04/05
Employee 
Spouse
Per Child 
Child(ren) Under Age 3 		 $21.80
$21.21
$20.52
No Charge
Freedom Basic
Benefit Maximum,
Per Person, Per Policy Year ............ $1,000

Insured Percentage Allowable Charge
Type I Dental Services...................... 100%
Type II Dental Services...................... 80%

Deductible,
Per Person, Per Policy Year ..............$50
This deductible applies to Type II  Services only. 
(Waived for (Type I) Services)

Type I Dental Services, Including:
  • Routine Oral Examinations

    • - once every 6 months in a row
  • Routine Dental Cleanings

    • - once every 6 months in a row 
    (Frequencies combined with Periodontal Maintenance)
  • Flouride Treatment - once every 12 months in a row 

    • Only for children under age 14
  • Sealants - once per permanent molar teeth

    • Only for children under age 16
  • Space Maintainer (includes adjustments within 6 months of installation)  Only for children under age 16 
  • Harmful Habit Appliance - once per person 

    • Only for children under age 16 
    (Not covered if Orthodontic related)
  • Bitewing X-Rays - once every 12 months
Type II Dental Services, Including:
  • X-Rays:
    • Complete Series - once every 60 months
    • Panoramic - once every 60 months (may also be payable in connection with removal of impacted teeth)
    • Other X-Rays (See Certificate of Insurance) 
  • New Fillings; Replacement Fillings - once every 24 months per Filling 
  • Simple Extractions, Removal of Exposed Roots, Incision and Drainage 
  • Certain Lab Tests, Pain Treatment, Therapeutic Drug Injections
  • Minor Gum Disease Treatment: (Minor Periodontics) 
  • Provisional Splinting, Occlusal Adjustments - once every 12 months 
  • Scaling and Root Planing -once every 24 months per area
  • Periodontal Maintenance - once every 6 months (Frequencies combined with Routine Dental Cleanings)
Other Policy Provisions

ImportantLimitations and Exclusions

Benefit Adjustments
Benefits will be coordinated with any other dental coverage.  Under the Alternative Treatment provision, benefits will be payable for the most economical services or supplies meeting broadly accepted standards of dental care.  If the cost of a proposed Dental Treatment Plan exceeds $300, it should be submitted for an estimate of benefits payable.

Eligibility
Full-time employee,, spouse and unmarried dependent children less than age 19, or less than age 25 if a full-time student.  Dependent eligibility variation exists in some states.  Please refer to your Group Policy.

Late Entrants
If you elect coverage more than 31 days after your  Eligibility Date, your Effective Date will be delayed to the next plan Anniversary Date.
This is a brief description only. It is not a Certificate of Coverage. Please see the Group Policy, which alone determines all rights, benefits, and applicable Limitations and Exclusions. Fortis Benefits and the policyholder have the option to cancel the group policy.
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