Covered Dental Services In-Network* 
You Pay Out-Of- 
Network** 
You Pay Benefit Limitations Per 
Calendar Year 
Major Dental Services (Endodontics, Periodontics, and Oral Surgery) 
Partial dentures (including routine 
post-delivery care) 70% 75% One upper and/or one lower 
partial denture every five years 
Denture adjustments (not covered 
within six months of initial 
placement) 70% 75% One per year 
Denture reline (not allowed on 
spare dentures) 70% 75% One per year 
Denture rebase (not covered