Caldwell County Schools Voluntary Dental Benefit Plan

As a valued employee of Caldwell County Schools, you have the opportunity to enroll in a payroll-deduction dental program. This plan provides a variety of benefits and allows you and your family to use any dentist or specialist you choose. Claim payments may be made to you or your dentist, whichever you prefer.

10-Month Payroll Deduction

Summary of Benefits

Type B Basic Dental Services, Including:

 New Fillings, including posterior composites

 Replacement Fillings – once every 24-months

 Extractions

 Certain Lab Tests, Pain Treatment, Therapeutic Drug Injections

 Endodontics (includes root canal therapy)

 Endodontic retreatment (covered after 24 months from initial treatment)

 Complex Oral Surgery

Type C Major Dental Services, Including:

 Minor Gum Disease Treatment: (Minor Periodontics)

- Provisional Splinting, Occlusal Adjustments – once in a 12month period

- Scaling and Root Planing – once in a 24-month period

Type A Preventive Dental Services, Including:

 Oral Evaluations – twice per plan year

 Routine Dental Cleanings – twice per plan year (frequency combined with periodontal maintenance)

 Fluoride Treatment – once every 12 months; only for children under age 14

 Genetic Test for Susceptibility to Oral Diseases – once per Lifetime; over age 18 only

 Sealants – once per tooth, only for permanent molar teeth; only for children under age 16

 Space Maintainer - only for children under age 16

 Bitewing X-Rays – every 12 months

 X-Rays:

- Panoramic or complete series – once every 60 months

- Certain other x-rays

- Periodontal Maintenance – once in 90 days (frequency combined with routine dental cleanings; combined total not to exceed 4)

 Localized Delivery of Antimicrobial Agents

 Major Gum Disease Treatment: (Major Periodontics)

- Gingivectomy, Osseous Surgery, other major periodontic procedures – once in a 36-month period per area

 Initial Placement, Replacement and Maintenance of Inlays, Onlays, Crowns, Fixed Partial Dentures (Bridges), and Partial and Complete Dentures.

Type D Orthodontic Dental Services

Dependent children under age 19 only

 Limited, Interceptive, and Comprehensive Orthodontic Treatment

 Minor Treatment to control harmful habits

This is a brief description only. Please see the Plan Document, which alone determines all rights, benefits, and applicable Limitations and Exclusions.