What services are covered Under the Competitor Smile Dental Insurance Plan?

Preventive Services

Routine oral examinations of mouth and teeth: 2 per calendar year
Prophylaxis (cleaning, scaling and polishing teeth), 2 per calendar year
Topical fluoride, 1 per calendar year to age 16
Space maintainers (non-orthodontic)

Basic Services

Diagnostic X-rays (full or panoramic), 1 in any 3 year period
Bitewing X-rays: 2 per calendar year
Simple extraction of one or more teeth
Pin retention of fillings
Fillings (restorations) using amalgam, silicate, acrylic, synthetic porcelain and composite filling materials
Antibiotic injections administered by a Dentist
Oral surgery and postoperative care for removal of one or more teeth, extraction of tooth root, alveolectomy, alveoplasty, frenectomy, excision for biopsy, reimplantation or transplantation of a natural tooth, excision of a tumor or cyst and incision and drainage of an abscess or cyst
General anesthesia and analgesic, including intravenous sedation for oral surgery

Major Services

Endodontic treatment of diseases of the tooth, pulp, root and related tissue
Periodontic services
Study models, 1 in a 3 year period
Crown build-up for non-vital teeth
Recementing and restoration of inlays, onlays and crowns
Recementing bridges
Repairs to full or partial dentures or bridges, one every 2 years
Prosthetic services (dentures or bridgework)

What is a Reasonable and Customary Fee?
This plan reimburses you for covered dental expenses based upon "Reasonable and Customary" fees. Reasonable and Customary fees are charges that do not exceed the general level of charges being made by other providers of dental services in the geographic area where the charge is incurred.

This site provides a brief description of the benefits, exclusions and other provisions of the policy or certificate Form Master Policy #GH-1112-38090 issued to the voluntary Group Trust. For a complete listing, see the policy or certificate. Benefits may vary in different states. This dental insurance plan may not be available in all states. ©2005 HPA, Inc. All rights reserved.
S105121 (10/03)