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Variations from Standard Benefit Plans

Please refer to the policy approved in your state for specific details. In the event of a discrepancy between items listed below and your policy, the policy will control. Contact your sales representative for additional details or to review policy documents.

AZ: Coverage for certain prescription drugs related to dental services is available upon request.

CO: Orthodontic treatment for cleft lip or cleft palate are covered services when medically necessary.

MD: Prophylaxis (cleanings) are limited to one service per 120 days. Fluoride treatment is limited to one service per 120 days under a certain age; refer to policy documents for age restriction. Oral evaluations (exams) are limited to one service per 120 days. Detailed problem focused exams are eligible for one service per 120 days per eligible diagnosis.

MN: Plans include coverage for certain services related to the treatment of temporomandibular joint and craniomandibular joint disorder are covered services with any policy issued in Minnesota.

NM: Plans include coverage for certain services related to the treatment of temporomandibular joint and craniomandibular joint disorder for any policy issued in New Mexico. Coinsurance values listed in quotes requested by prospective clients show the company responsibility. Please see your plan documents for a listing of covered services which list member coinsurance responsibility.