||Per Pay Period
Procedure Coverage and limits (Percentage shown per covered person)
Type I – Preventive Procedures: 100% Coverage
- routine examinations
- x-ray examinations
Type II – Basic Procedures: 80% Coverage
- regular cavity fillings
- non-surgical tooth extractions
- repair of crowns and bridges
- removal of wisdom teeth
Type III – Major Procedures: 50% Coverage
- abutment crowns
- initial full or partial dentures
Type IV – Orthodontics Procedures: 50% Coverage
The Deductible (per person per calendar year) does not include Type I Services and has a benefit limit of $50. The Calendar Year Maximum for Types I, II and III combined per covered person has a benefit limit of $1,500. The Lifetime Maximum (Orthodontics per covered person) for Type IV has a benefit limit of $1,500.
There are no network limitations on which dentist you choose.
Examples are limited and do not include all applicable services.
For more information about PCRMC’s benefits, please contact Cathy Moore at 573-458-7168 or by email at firstname.lastname@example.org.