planing (deep cleaning) 70 % 75 %One procedure for each quadrant 
per year 
Scaling –generalized 
inflammation  70 % 75 % One procedure per year  
Complete dentures (including 
routine post-delivery care) 70% 75% One upper and/or one lower 
complete denture every five years 2023 OPTIONAL SUPPLEMENTAL BENEFITS – 25 OPTIONAL SUPPLEMENTAL BENEFITS S(continued) 
Covered Dental Services In-Network* 
You Pay Out-Of- 
Network** 
You Pay Benefit Limitations Per 
Calendar Year