Kanawha Group dental plus

The High Option Plan is a group dental expense insurance plan designed to provide coverage that’s right for you and your family.

PLAN FEATURES:
	¬ Orthodontic benefits are included for adults at no extra cost
¬ You select the dentist you want to see	¬ Fast, personalized claims service is provided
¬ Benefits provided on a calendar year basis	¬ Calendar year maximum of $1,500 per covered person
¬ Unisex rates	¬ Deductible for Class II, Class III and Class IV may be combined
¬ Ease of payroll deductions	¬ Maximum of 3 deductibles per family per calendar year
¬ Benefit payments for services are subject to usual, customary, reasonable limits and to calendar year maximums

Benefits Include:  

Class I – Diagnostic and Preventative Services

Reimbursed at 100% and are not subject to a deductible

Emergency pain relief treatment

Covers one clinical oral examination in any six consecutive month period

Covers one routine full mouth series x-ray in any 36 consecutive month period

Covers one routine bitewing x-ray in any six consecutive month period

Covers two dental cleanings in any 12 consecutive month period

One fluoride treatment in any 12 consecutive month period for children

prior to their 19^th birthday

Space maintainers for children prior to their 19^th birthday

One sealant treatment per tooth in any 36 consecutive month period

for children ages 5-14, subject to a lifetime maximum of two treatments

per tooth

Class II – Restorative and Corrective Services

Reimbursed at 80% and are subject to a $50 deductible, subject to a 6 month waiting period

Fillings (except gold fillings. See Class III.)

Endodontics-pulp capping, pulpotomy, and root canal therapy

Oral surgery-gingivectomy, alveoplasty, extraction of teeth, surgical extractions of teeth, alveolectomy, frenectomy and apicoectomy

General anesthesia-if medically necessary, administered with oral surgery and produces a state of unconsciousness

Class III – Major Restorative and Corrective Services

Reimbursed at 50% and are subject to a $50 deductible, and subject to a 12 month waiting period

Repair or recementing of crowns, inlays, bridgework or dentures or relining of dentures (once in any 36 consecutive month period)

Inlays, gold fillings, or crowns

Initial installation of fixed bridgework to replace natural teeth removed while covered

under the Summary Plan Description (SPD)

Initial installation of partial or full removable dentures to replace natural teeth extracted

while covered under SPD

Periodontics (treatment of gum diseases)

Replacement of an existing partial or full removable denture or to fixed bridgework if

one of the following conditions applies: the replacement or addition of teeth is needed to

replace teeth extracted after the existing denture or bridgework was installed, and while

covered under the SPD; the existing denture or bridgework cannot be made serviceable

and was installed at least five years prior to its replacement; or the existing denture is

an immediate temporary denture and replacement by a permanent denture is required

within 12 months from the date of the initial installation.

Class IV – Orthodontic Services

Benefits for all covered insureds (adults and children), to $500 per covered person per calendar year

Reimbursement at 50% and are subject to a $50 deductible

Exclusions, Exceptions and Limitations:

 Benefits for certain kinds of dental expenses are not covered by the group policy:

Braces and orthodontic services (except as specifically provided for in the Optional Class IV benefit provisions)	Supplies or services performed or commenced before the group policy became effective, except as specifically provided in the Optional Class IV benefit provisions
Services or supplies covered by any other dental insurance policy or SPD paid for by, or through, the Employer	Services other than those specifically covered under the group policy
Charges which exceed usual, customary and reasonable limits	Treatment by someone other than a dentist/physician, except that cleaning or polishing of teeth and topical application of fluoride may be performed by a licensed dental hygienist under the supervision of a dentist/physician
Charges for treatment of any job-related accident covered by Workers’ Compensation or other similar law	Charges for cosmetic dentistry unless required as a result of a non-occupational accident sustained while the group policy is in force
Charges for duplicate prosthetic devices or appliances (e.g., dentures, bridgework), for replacement of lost or stolen prosthetic devices or for replacement of prosthetic devices less than five years old except as may be specifically provided in the Class III benefit of the group policy	Treatment not meeting accepted standards of dental practice
Charges for plaque control or other educational programs	Charges for services or supplies which are not necessary according to accepted standards of dental practice
Charges for experimental services	Charges for missed appointments or for the time spent completing or filing claim forms
Services or supplies for which no charge is made that you are legally obligated to pay or for which no charge would be made in the absence of dental expense coverage	Myofunctional therapy
Periodontal splinting	Services to alter vertical dimension
Surgical procedure for augmentation, segmentation or repositioning of the mandible or maxilla

Premium Rates

Group Dental Plus	Monthly
Employee	$31.24
Employee and Spouse	$62.49
Employee and Child(ren)	$68.74
Employee and Family	$99.98

Policy is underwritten by: Kanawha Insurance Company

P.O. Box 610

Lancaster, SC 29721-0610

(803) 283-5300

(800) 635-4252