The District's dental plan is covered by the Excellus Smile Saver Dental Assistance Plan. If you receive this benefit, here's an overview of what is covered.

Service	Time Frame		Allowance
Preventative and Diagnostic Services
Initial and/or Periodic Exams		Twice per calendar year	Payable at 100% of the Plan allowed amount or charges, whichever is less
Cleaning, scaling, and polishing of teeth		Twice per calendar year
Topical fluoride application for members under age 19		Twice per calendar year
Bitewing dental x-rays		Twice per calendar year
Full mouth x-ray series or panoramic x-ray		Once in three years
Sealants: for members under age 16.		Allowed once per tooth in 36 consecutive months on first and second unrestored permanent molars.
Palliative emergency exam to relieve pain.		Twice per calendar year
Basic Restorative Services
Fillings: amalgam (silver) or anterior resin (white) for treatment of cavities. Benefits for resin fillings placed on molar teeth are limited to the allowance of amalgam material. Bonding is not covered.		Once per surface in 12 months	Payable at 50% of the Plan allowed amount or charges, whichever is less. Subject to Plan deductible.
Periodontal surgery: gingivectomy or osseous surgery		Once per quandrant in 36 months
Periodontal root planning and scaling		Once per quadrant in 24 months
Extractions: Routine and surgical		n/a
Root canal treatment		n/a

Major Restorative Services: Alternate Benefits Enforced
Payable at 50% of the Plan allowed amount or charges, whichever is less. Subject to the Plan deductible.

Prosthetics: crowns, inlay/onlay, complete or partial dentures, bridge abutments/pontics.

• Benefits for replacement of an existing prosthetic is allowed only if more than five years have lapsed since last placement that was covered under a dental plan.
  
• Replacement of a partial denture with fixed bridgework or replacement due to loss or theft is not covered.
  
• Benefits for replacement of multiple missing teeth and/or bilaterally missing teeth are allowed as a partial denture. Double abutments are not covered.
  
• Benefits for crown/inlay/onlay are allowed only when teeth cannot be restored by a filling, and if more than 5 years lapsed since that initial placement. Benefits for upgrading fillings to crown/inlay/onlay are limited to the allowance of a filling.
  
• Benefits for porcelain/resin (white) material placed on molar teeth are limited to the allowance of metallic material.
  
• Space maintainers for members under age 19 - once in 5 years

Orthodontic Services
For members under age 19— Payable at 50% of the allowed amount or charges, whichever is less, up to a lifetime maximum. Subject to deductible.

Dental Claim Form (pdf file - 133 KB)

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