Periodontal maintenance 0% 50% Four per year 
Basic Dental Services (Minor Restorative) 
Amalgam restorations (silver 
fillings) 
Composite resin restorations 
(white fillings) 50% 
50% 55% 
55% Two per year 2023 OPTIONAL SUPPLEMENTAL BENEFITS – 23 OPTIONAL SUPPLEMENTAL BENEFITS S(continued) 
Covered Dental Services In-Network* 
You Pay Out-Of- 
Network** 
You Pay Benefit Limitations Per 
Calendar Year 
Basic Dental Services (Minor Restorative) 
Extractions (pulling teeth), simple