Basic Dental has lower allowed amounts, which are the maximum amounts allowed by the plan for a covered service. There is no network for Basic Dental; therefore, providers can charge you for the difference in their cost and the allowed amount. Basic Dental benefits are paid based on the allowed amounts for each dental procedure listed in the Plan’s Schedule of Dental Procedures and Allowed Amounts. Your dental benefits are divided into four classes:

• Diagnostic and preventive (exams, cleanings, X-rays): You do not pay a deductible. The Plan will pay 100 percent of a lower allowed amount. A provider can charge you for the difference in its cost and the allowed amount.
• Basic (fillings, oral surgery, root canals): You pay up to a $25 deductible per person.¹ The Plan will pay 80 percent of a lower allowed amount. A provider can charge you for the difference in its cost and the allowed amount.
• Prosthodontics (crowns, bridges, dentures, implants): You pay up to a $25 deductible per person.¹ The Plan will pay 50 percent of a lower allowed amount. A provider can charge you for the difference in its cost and the allowed amount.
• Orthodontics² (limited to covered children ages 18 and younger): You do not pay a deductible. There is a $1,000 lifetime benefit for each covered child.

The maximum yearly benefit for a person covered by Basic Dental is $1,000 for diagnostic and preventive, basic and prosthodontics services. Not all dental procedures are covered. You will be responsible for any charges related to non-covered services. More information about non-covered services is available in the Insurance Benefits Guide.