Open Access Option (See Any Dentist You Choose)

1st Year

2nd Year

3rd Year**

Preventive & Diagnostics

100%

100%

100%

2 exams per calendar year
2 Prophylaxis (cleaning) per calendar year
Space Maintainers


1st Year

2nd Year

3rd Year**

Basic Restorative

40%

80%

80%

Bitewing x-rays, two per calendar year
One fluoride treatment per calendar year for dependents to age 16
Simple extractions/ Fillings Full mouth or panoramic x-rays once every 3 years


1st Year

2nd Year

3rd Year**

Major Services

25%

50%

50%

Oral Surgery
Bridges
Crowns
Periodontics
Endodontic


1st Year

2nd Year

3rd Year**

Orthodontic Services

10%

25%

50%

For children under age 19



We will pay the usual and customary charge for dental procedures and services after
any required deductible amount, as shown below. | $50 lifetime preventive deductible
| *$50 annual deductible basic & major services (3 per family)
$1000 annual maximum for Preventive, Basic & Major services combined per person.
$500 annual/$1000 lifetime maximum for ortho services for dependent children.
**and every year thereafter


Vision Benefits Rider (Optional on all Landmark Dental Plans)

Coverage for Exams Frames Lenses Contact Lenses
Services Offered: Lifetime-Per Person Deductible of $50.00 on Lenses and Frames
Examination $50.00 (once every calendar year with $10 copay)
A routine, complete eye examination, refraction, and prescription for eyeglasses.
Contact lens examinations require additional fees.
If indicated, your doctor may recommend additional procedures, which are the
responsibility of the member.
Frames (once every 24 months) $65.00
Lenses (once every 12 months) Single $40.00 Bifocal $60.00 Trifocal $70.00
No line bifocal or progressive power or Lenticular $100.00
Contact Lenses (in lieu of lenses and frames) $100.00

PPO Plan Coverage

(Perferred Providers)

(Non-Perferred Providers)

1st Year

2nd Year

3rd Year **

|

1st Year

2nd Year

3rd Year**

Preventive & Diagnostics

100%

100%

100%

|

100%

100%

100%

2 exams per calendar year
2 Prophylaxis (cleaning) per calendar year
Space Maintainers


1st Year

2nd Year

3rd Year**

|

1st Year

2nd Year

3rd Year**

Basic Restorative

60%

90%

90%

|

50%

80%

80%

Bitewing x-rays, two per calendar year
One fluoride treatment per calendar year for dependents to age 16
Simple extractions/ Fillings
Full mouth or panoramic x-rays once every 3 years


1st Year

2nd Year

3rd Year**

|

1st Year

2nd Year

3rd Year**

Major Services

20%

60%

60%

|

10%

50%

50%

Oral Surgery
Bridges
Crowns
Periodontics
Endodontic


1st Year

2nd Year

3rd Year**

|

1st Year

2nd Year

3rd Year**

Orthodontic Services

10%

25%

50%

|

10%

25%

50%

For children under age 19



For Preferred Provider (PP) and Non-Preferred Provider (NPP) services, we will pay based on the contracted fee
amount negotiated with the preferred provider organization, after any required deductible amount or waiting period
as shown below. | $50 lifetime preventive deductible | *$50 annual deductible basic & major services (3 per family)
$1000 annual maximum for Preventive, Basic & Major services combined per person.
$500 annual/$1000 lifetime maximum for ortho services for dependent children. | **and every year thereafter


Vision Benefits Rider (Optional on all Landmark Dental Plans)

Coverage for Exams Frames Lenses Contact Lenses
Services Offered: Lifetime-Per Person Deductible of $50.00 on Lenses and Frames
Examination $50.00 (once every calendar year with $10 copay)
A routine, complete eye examination, refraction, and prescription for eyeglasses.
Contact lens examinations require additional fees.
If indicated, your doctor may recommend additional procedures, which are the responsibility of the member.
Frames (once every 24 months) $65.00
Lenses (once every 12 months) Single $40.00 Bifocal $60.00 Trifocal $70.00
No line bifocal or progressive power or Lenticular $100.00
Contact Lenses (in lieu of lenses and frames) $100.00

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