Deductibles, coinsurance and benefit maximums are per Covered Person.

Preventative Services (immediate coverage - no waiting period)

• 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 (subject to a 6 month waiting period)

• 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 (including impacted teeth), extraction of tooth root, alveolectomy, alveoplasty, frenectomy, excision of periocoronial gingiva, exostosis, hyperplastic tissue, excision or oral tissue for biopsy, reimplantation or transplantation of a natural tooth, excision of a tumor or cyst and incision and drainage of an abscess or cyst.

Special Services  (subject to a 18 month waiting period)

• General anesthesia and analgesic, including intravenous sedation for oral surgery
• Endodontic treatment of diseases of the tooth, pulp, root, and related tissue
• Periodontic Services
• Study models, one in a 3 year period

Major Services (subject to a 24 month waiting period)

• Crown build-up for non-vital teeth.
• Recementing inlays, onlays and crowns.
• Recementing bridges.
• Repairs to full or partial dentures or badges, one in any 2 year period and not more than 20% of the cost of replacement (repairs within one year of placement are not covered)
• Restoration services (inlays; onlays; crowns)
• Prosthetic services [dentures; bridgework)

NOTICE: This site provides a very brief description of some important features of The Competitor Smile Dental Plan. The complete terms, provisions and conditions of coverage are described in the actual Certificate of Insurance that will be issued upon approval of application. AlI benefits are subject to the master policy series GH-112-3603 issued to the Voluntary Group Trust.

ELIGIBLE EXPENSES: Expenses must be incurred while the Policy is in force and the person is covered by the Policy. To be an Eligible Expense, the dental services must be performed by:

• a licensed Dentist acting within the scope of his license;
• a licensed Physician performing dental services within the scope of his license; or
• licensed dental hygienist acting under the supervision and direction of a Dentist.

EXPENSES INCURRED: An Eligible Expense is considered incurred on the following dates:

• for full and partial dentures - on the date the final impression is taken.
• for fixed bridges, crowns, inlays and onlays - on the date the teeth are first prepared.
• for root canal therapy - on the date the pulp chamber is opened.
• for periodontal surgery - on the day surgery is performed.
• orthodontic services - on the date the appliance or bands are inserted or on the date a one-step orthodontic procedure is performed.
• for all other services - on the date the service is performed.

EXPENSES NOT COVERED: No benefits will be paid for expenses incurred:

• for any portion of a charge for any service in excess of the Scheduled Benefit.
• for any procedure not listed as a Scheduled Benefit.
• for overdentures and associated procedure.
• for cosmetic procedures for replacement of full and partial dentures.
• bridges, inlays, onlays or crowns that can be repaired or restored to normal function.
• for implants; and for (a) the replacement of lost or stolen appliances; (b) the replacement of orthodontic retainers; (c) athletic mouthguards; (d) precision or semi-precision attachments; (e) denture duplication; or for (f) sealants. for oral hygiene instructions; and for (a) plaque control; (b) the completion of claim form; (c) acid etch; (d) broken appointments; (e) prescription or take-home fluoride; or for (f) diagnostic photographs.
• for services not completed by the end of the month in which coverage terminates.
• for procedures that begun, but not completed.
• for those services for which there would be no charge in the absence of insurance or for any service or treatment provided without charge.
• for services in connection with war or any act of war, whether declared or undeclared, or condition contracted or accident occurring while on full-time active duty in the armed forces of any country or combination of countries
• for care or treatment of a condition for which you are entitled to or eligible for benefits under any Worker's Compensation Act or similar law.
• that are applied toward satisfaction of a Deductible, if any:

ALTERNATE BENEFIT: (1)If we determine that a less expensive alternative procedure, service or Course of Treatment can be performed in place of the proposed treatment to correct a dental condition; and (2) the alternative treatment will produce a professionally satisfactory result; then the maximum we will allow will be the charge for the less expensive treatment.