every 5years. 
•50% of the cost for bitewing  
x-rays, intraoral x-rays up to 1  
set(s) per year. 
•50% of the cost for periodic  
oral exam, prophylaxis  
(cleaning) up to 2per year. 
•50% of the cost for necessary  
anesthesia with covered service  
up to unlimited per year. You do not need areferral to receive covered services from plan providers. Certain procedures, services and drugs 
may need advance approval from your plan. This is called a"prior authorization" or "preauthorization." Please