Charges for reasonable and customary services and specified supplies shall be considered covered expenses when incurred by you or a covered Dependent. Eligible expenses include Basic and Preventive Treatment, Endodontics, Periodontics, Oral Surgery, Major Restorative and Prosthodontics. An expense is eligible to the extent that coverage is not prohibited by provincial health insurance plans or because of other limitations described below.
Percent Payable
Basic Procedures
Calendar Year Maximun for both Basic and Major procedures combined
Complete examination
Recall or Specific exam
Full mouth x-ray
Bitewing x-rays
Scaling or root planning
Pit & Fissure sealants
study casts
relining and rebasing of existing dentures
100%
$2,000
once every 24 months
once every 9 months
once every 24 months
once every 6 months
8 units per year
once per tooth, under 18
once every 12 months
once every 12 months
The following are considered Basic Procedures:
oral examinations including scaling and cleaning of teeth
topical application of sodium or stannous fluoride
dental x-rays: single diagnostic x-rays; Panorex/complete series
consultations
extractions
oral surgery including excision of impacted teeth
amalgam, acrylic, silicate or composite fillings
retentive pins
anaesthesia where reasonably and customarily required in connection with other covered procedures
occlusal equilibration
periodontal scaling
treatment of periodontal and other diseases of gums and tissues of the mouth
caries, trauma and pain control
emergency endodontic procedures and root canal therapy
prefabricated full coverage restorations for primary teeth
stainless steel crown restorations on primary teeth
space maintainers for missing primary teeth and habit breaking appliances
pit and fissure sealants for Dependent Children under the age of 18 only
study casts, once every 12 months
relining and rebasing of existing dentures, once every 24 months