SCHEDULE OF DENTAL EXPENSE BENEFITS
CITY OF LEWISVILLE
Plan Benefits Effective: October 1, 2007
| Maximum Benefit for Preventative, Basic and Major | $1,250 |
| Maximum Benefit for Child Orthodontic | $1,000 |
| Waiting Period |  |
| Major Services | 1 year |
| Orthodontic Services | 2 years |
| Calendar Year Maximums | |
| Preventative Care | 100%, no plan deductible |
| Office Visit, Oral Examination | 2 visits |
| Prophylaxis under age 14 | 2 treatments |
| Prophylaxis age 14 or over | 2 treatments |
| X-rays - Complete Series | 1 every 3 years |
| Topical Application for Fluoride (including prophylaxis) | 1 treatment |
| Bitewing X-rays | 2 times per year |
| Sealants (for individuals 19 or under) | 1 every 3 years |
| Fixed Space Maintainer (limited to nonorthodontic treatment) | |
| Deductible for Basic and Major for Individual | $50 |
| Deductible for Basic and Major for Family | $150 |
| Pre-determination is recommended on all services of $300 or more | |
| Basic Dental Benefits | 80% |
| Anesthetics | |
| Oral Surgery | |
| Impacted Teeth | |
| Periodontics | |
| Endodontics | |
| Major Dental Benefits | 50% |
| Implants | |
| Crowns | |
| Fixed or Removable Appliances | |
| Bridge Pontics | |
| Child Orthodontic Benefit | 50% |
| Maximum Lifetime Benefit for covered participants age 19 or less. | |
