Maximum Amount Payable:

Per Person per Calendar Year except for Pediatric.	$2,000
Per Family per Calendar Year except for Pediatric:	$4,000

Benefits Payable:

All other Dental Services:

100% of the usual and customary charge, not to exceed the Maximum Covered Charge stated in the List of Covered Dental Procedures. (page 32 )

If You or Your Dependent incur expenses for a service in the “List of Covered Dental Procedures,” benefits will be payable to the extent that they:

1. Are usual and customary
2. Constitute necessary treatment
3. Are incurred while You or Your Dependents are covered for this benefit

The Plan will pay the amount of eligible expenses indicated in the Schedule of Benefits. The maximum amount allowed for dental services is also found in the Schedule of Benefits.

LIMITATIONS

There is no coverage for loss caused by or resulting from:

1. A service furnished to You or Your Dependent for:
   1. Cosmetic purposes, unless needed as the result of an injury
   2. Dental care of congenital or developmental malformation except for Orthodontic services
2. Replacement of a lost or stolen appliance
3. A service not furnished by a Dentist, except:
   1. Services of a dental hygienist, and
   2. X-rays ordered by a dentist
4. Appliances, restorations or procedures for the purpose of altering vertical dimension, restoring or maintaining occlusion, splinting or replacing structure lost as a result of abrasion or attrition or treatment of disturbances of the temporomandibular joint. The replacement of any prosthetic appliance, crown, inlay or onlay restoration or fixed bridge within 5 years of the date of the last placement, unless replacement is needed as a result of injury.
5. An initial placement of a partial or full removable denture or fixed bridgework which involves the replacement of one or more natural teeth, unless the teeth are extracted while covered for this benefit.
6. Services performed for the teeth, nerves of the teeth, gingivae or alveolar process except for tumors or cysts, or because of accidental injury, while covered, to sound natural teeth. This includes the initial replacement of these teeth and any necessary dental x-rays resulting from an accident occurring while covered, provided You receive treatment within twelve months of the accident.
7. All claims must be submitted within twelve (12) months of the date of service.
8. There is a lifetime maximum benefit of $500 per implant, payable for 1 implant per jaw lifetime, (total of 2) for implant codes 6010, 6020, 6040 and 6050. Panel dentists do not have to accept these fees as payment in full; it is an allowance towards the full implant fee.