Only available with selection of
Sentry Student Security Plan II
(Additional Premium Required- See Rate Chart)
DENTAL BENEFITS
BENEFITS
If an Insured incurs charges for Dental Services while the Policy is in effect and the Insured is covered under the Dental Benefit, Sentry will pay the percentage shown in the Dental Services section and which:
a. Do not exceed the Reasonable and Customary charges for the Dental Services; and
b. Do not exceed the policy year maximum per Insured of $1,000; and
c. Are in excess of the policy year deductible per Insured of $50.
DENTAL SERVICES
Class I Services (80% of Covered Charges)
-
a. Initial and Periodic Oral examinations, required x-rays and prophylaxis;
b. Topical application of fluoride for Insureds under age 14;
c. Sealants for Insureds under age 14;
d. Emergency oral examination for pain relief.
a. Acrylic, amalgam, plastic, porcelain, silicate or stainless steel restorations;
b. Oral surgery including extractions;
c. Endodontics;
d. Periodontics;
e. Individual crowns;
f. Bridges;
g. Initial dentures;
h. Space maintainers.
Only Available with Purchase of Plan II
Sentry Student Security Plan
| Persons Insured | Health Plan I | Health Plan II |
|---|---|---|
| Student Only | Not Available | $25 |
| Student & Spouse | Not Available | $51 |
| Student, Spouse & Children | Not Available | $81 |
| Student & Children Only | Not Available | $55 |
DENTAL LIMITATIONS
Benefits for Dental Services are limited as follows:
- There must be at least six months between each oral examination, bitewing x-ray and prophylaxis treatment or service.
- There must be at least three years between each complete mouth x-ray.
- Coverage for Class II Dental Services begins six months after the effective date of continuous coverage for Class I Dental Services.
ELECTIVE LIMITATION
If an Insured elects a more expensive procedure than is usually given, benefits will be limited to the cost based on a standard procedure.
DENTAL EXCLUSIONS
No benefit will be paid for charges incurred:
-
1) for any service not listed in the Dental Services;
2) for any service performed for cosmetic reasons. This exclusion will not apply to procedures performed as a result of congenital defects of a newborn Child;
3) charges for which an Insured has benefits provided under any Workers’ Compensation or Occupational Disease Law;
4) for general anesthesia except when administered for a covered Oral Surgery procedure performed by a dentist;
5) for oral hygiene instructions and dietary instructions;
6) for plaque control programs;
7) for charges for hospital services;
8) for Myofunctional Therapy;
9) for treatment of temporomandibular joint dysfunction (TMJ);
10) for hypnosis;
11) for any operation or service not performed by a Doctor or dentist;
12) for surgery required to restore occlusion;
13) for dentures which have been lost, mislaid, or stolen;
14) for orthodontics or interceptive orthodontia;
15) for dental implants;
16) for inlays, onlays or gold fillings;
17) for replacement prosthodontic appliances, cast restorations, individual crowns and jackets;
18) for prescription drugs.