Affordable Dental Plan - through your MRTA Membership!

Preventive Care (deductible waived for these services)

• Comprehensive oral examination: Once in any 36 consecutive month period
• Periodic routine examinations: Once in any 6 month consecutive month period
• Bitewing x-rays: 2 series of 4 bitewing x-rays in a 12 month period, separated by an interval of 6 months
• Full mouth x-rays: Once in any 36 consecutive month period
• Prophylaxis: Cleaning, scaling once in any 6 consecutive month period
• Topical flouride treatment: Once in any 12 consecutive month period for a dependent child under 16 years of age
• Space maintainers: Once in 5 years to replace prematurely lost teeth for a dependent child under 16 years of age

Basic Care (deductible applies to these services)

• Restorations/Fillings: Amalgam, silicate, acrylic or plastic restorations (excluding gold)
• Extractions: Simple & surgical extractions, including extractions connected with orthodontia
• Emergency palliative treatment: As required for treatment or severe pain, swelling or bleeding
• Sealant treatment for molars and pre-molars: 1 treatment per tooth for permanent molars and pre-molars in any 36 month period for a dependent child under 16 years of age

Major Care - 6 Month Wait Major Services (deductible applies to these services)

• Endodontics: Pulp capping, pulpotomy and root canal therapy
• Periodontics: Nonsurgical and surgical procedures necessary for the treatment of diseases of the gums and bone supporting the teeth; includes periodontal scaling and root planing (once in a 24 month period in the same quadrant), gingivectomy/gingivoplasty; Osseous surgery/Osseous graft, splinting
• Periodontal maintenance, following active therapy: Benefits payable for periodontal maintenance are limited to 1 per 12 month period (not related to prophylaxis)
• Inlays, onlays and crowns: Except in the case of accidental injuries, replacement of a crown, inlay or onlay is covered only once in any 5 year period and then only if existing crown, inlay or onlay cannot be made satisfactory and not during the first year of coverage
• Installation of prosthodontics: Complete or partial dentures, bridges, pontics and abutment crowns; coverage for partial or full upper and lower dentures shall be limited to one partial or full upper and lower denture in any 5 consecutive year period of coverage; but replacements are not during the first year of coverage for new enrollees
• Maintenance of prosthodontics: Repair of recementing of crowns, onlays, bridgework or dentures when performed more than 6 months after installation
• Relining or rebasing or dentures: Covered when performed more than 6 months after installation, but not more than once in a 36 month period
• All other oral surgery services
• Anesthesia: General anesthesia and IV sedation are covered when medically necessary and administered in conjunction with oral or dental surgery

Out of Network Services - All out-of-network claims are paid at the fee schedule

Limitations - Certain services and procedures may be subject to limitations under your Essex Dental Benefits program, as follows:

• If dental care is received from more than one dentist for the same procedure, benefits will not exceed what would have been paid for one dentist for that procedure
• If alternate treatments are available, benefits will not exceed an amount otherwise payable for the least costly professionally satisfactory treatment
• A Gross Debridement, limited to once in a lifetime, paid under Basic Services

Exclusions - Certain services and procedures are excluded from your Essex Dental Benefits program, as follows:

• Services provided solely to improve appearance or to correct congenital malformations
• Replacement of lost or stolen dentures and other dental appliances or duplicate appliances
• Nitrous oxide
• Any services not specifically stated as covered dental services, I.E. hospital, medical, prescription and non-prescription drugs
• Implants
• Treatment for malignancies, tumors or cysts
• Maxillofacial or orthognathic surgery, splint therapy or any treatment for temporomandibular joint disorders (TMJ), craniomandibular disorders or other conditions of the joint linking the jawbone and skull
• Replacement of a bridge or denture within 5 years following the original date of installation, and not during the first year of coverage for new enrollees
• Services or supplies not reasonably necessary for the care of the covered person or charges that exceed the usual, customary and reasonable limits
• Care covered under, or subject to, any worker's compensation law or federal employer's compensation or liability acts
• Services for which a covered person would normally incur no charge
• Experimental services, procedures or supplies
• Charges for hypnosis
• Charges which were a direct or indirect result of any act of war
• Charges for a partial or full removable denture, removable bridge or fixed bridgework if it includes replacement of one or more natural teeth missing prior to the covered person's effective date, unless the denture, bridge, or bridgework also includes replacement of a natural tooth that was removed while the person was covered either under the current plan or another group plan sponsored by the group immediately preceding the date of coverage under this plan or was not an abutment to a partial denture, removable bridge or fixed bridge installed during the prior 5 years
• Charges for complete occlusal adjustments in conjunction with temporomandibular joint therapy, crowns for occlusal correction, nightguards and bruxism appliances
• To the extent permitted by law, care received with or without charge from the Veteran's Administration, or from or through the state, county, city or political subdivision
• Tooth preparation, temporary crowns, temporary appliances, orthodontic retainers, bases, impressions and anesthesia or other services which are part of the complete dental procedure are considered components of and included in the fee for the complete procedure. Separate fees will not be eligible for benefits from the certificate
• Charges for oral hygiene instruction, OSHA charges or sterilization fees, missed appointments, completing a claim form and duplication of x-rays or dental records
• Charges from treatment that is already in progress prior to the covered person's effective date or charges incurred for treatment provided after coverage terminates