Eligibility:

Description

Single Coverage:

An average of at least 12 hours of work per week in the last 12 consecutive weeks of employment plus a processing month. For example, hours worked in August, September and October are processed in November, for December’s eligibility.

Family Coverage:

An average of at least 20 hours of work per week in the last 12 consecutive weeks of employment plus a processing month. For example, hours worked in August, September and October are processed in November, for December’s eligibility.

BASIC & MAJOR SERVICES MAXIMUM:

$2,000 per family member per calendar year

Basic Services:

These services include, but are not limited to:

• Exams, Fluoride, One Unit Of Polishing, 3 Units Of Scaling
  (These Services Are Covered Only Once Every 9 Months X-Rays: Periapical And Panoramic)
• Bite Wing X-Rays
  (Once Every 18 Months)
• Basic Fillings
  (Maximum of 5 surfaces in a 2-year period)
• Habit Breaking Appliances Simple Extractions

100%

Major Services:

• Crowns/Inlays/Onlays/Veneers/Bridges/Dentures (Once Every 5 Years* Periodontal Treatment)
• Oral Surgery/Complicated Extractions
• Endodontic Treatment *Refer to your Benefit Booklet, Plan Portal or contact PBAS for further clarification.

90%

Orthodontic Services:

$3,000 per family member per lifetime.

60%