Savings You Can See
Monthly Payroll Deduction Effective: 7-1-04/05
Employee 
Spouse
Per Child 
Child(ren) Under Age 3 		 $34.97
$34.32
$24.40
No Charge
Freedom Advance
Benefit Maximum,
Per Individual Benefit Year.......... $1,000

Coinsurance Percentage Per Person
Per Individual Benefit Year
 
Type I
Type II
Type III
During the lst year
100%
80%
10%
During the 2nd Year
100%
80%
25%
During the 3rd Year and thereafter
100%
80%
50%

Deductible,
Per Individual Benefit Year ...........$50
This deductible applies to Type II and Ill 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 - no more than once per tooth, only for permanent molar teeth 

    • Only for children under age 16 
  • Space Maintainer Only for children under age 16

    • (includes adjustments within 6 months of installation) 
  • 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 the 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
Type Ill Dental Services, Including:
  • Endodontics (includes root canal therapy) 
  • Endodontic retreatment (covered after 24 months have passed from initial treatment)
  • Complex Oral Surgery; General Anesthesia and IV Sedation when medically required for such Surgery 
  • 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) 
  • Major Gum Disease Treatment: (Major Periodontics)
    • Gingivectomy, Osseous Surgery, other major periodontic procedures - once every 36 months per area 
  • Initial Placement, Replacement and Maintenance of Inlays, Onlays, Crowns, Fixed Partial Dentures (Bridges), and Partial and

    • Complete Dentures
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.

To Vision Discount Plan Next page