This is a brief description of the benefits, exclusions and other provisions of the policy or certificate are listed in the Master Policy Certificate #GH-112-38090. All rights reserved.

Self Only: Includes only you, you are not required to enroll your dependants in the plan.

Self Plus Spouse: Includes you and your spouse, you are not required to enroll your eligible dependant children.

Self Plus Child or Children: Includes you and your child or children for single parents or those who do not want to enroll their spouse.

Self Plus Family: Includes you and all your eligible family members. 

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ON LINE APPLICATION AND ISSUANCE

SAMPLE COMPETITOR SMILE NALC FEDERAL EMPLOYEE DENTAL PLAN POLICY AND  COVERED DENTAL EXPENSES 

The Plan Will Pay The Current Usual And Customary Charge For Dental Procedures And Services After Any Required Deductible Amount, As Shown Below.

Class A. Preventive Services Include:

  The above sample policy is a sample of the Gold Plan and The Silver Plan would be identical except the Annual Maximum benefit for Gold is $1,500 and The Silver Plan is $1,000. The Bronze Plan would not include the covered benefits listed under Class C or Major Services and the Bronze Plan has a $750 Annual Maximum. All three Dental Plans have the same Dental Expenses Not Covered Section listed Below other then the Bronze Plan which would list that Services for Class C or Major Services are not covered by the Bronze Plan. The Bronze Plan only includes Class A and Class B Services.

DENTAL EXPENSES NOT COVERED

1. for overdentures and associated procedures.
2. for charges in excess of those considered to be reasonable and customary.
3. for cosmetic procedures.
4. for the replacement of dentures, bridges, inlays, onlays or crowns that can be repaired or restored to normal function.
5. for implants, and for:
   1. replacement of lost or stolen appliances;
   2. replacement of retainers;
   3. athletic mouthguards;
   4. precision or semi-precision attachments;
   5. denture duplication; or
   6. sealants;
6. for oral hygiene instructions; and for
   1. plaque control;
   2. completion of a claim form;
   3. acid etch;
   4. broken appointments;
   5. prescription or take home fluoride; or
   6. diagnostic photographs.
7. for services not completed by the end of the month in which coverage ends, unless continuation of coverage has been requested and accepted by Us.
8. for procedures that are begun, but not completed.
9. for services and treatment provided without charge or for which there would be no charge in the absence of insurance.
10. for services in connection with war or any act of war, weather declared or undeclared, or condition contracted or accident occuring while on full-time active duty in the armed forces of any country or combination of countries.
11. for a condition covered under any Worker's Compensation Act or similar law.
12. that are applied toward satisfaction of a deductible, if any.
13. that are generally considered by the dental profession as experimental or investigational.
14. for the treatment of cleft palate and anodontia.
15. for services or supplies payable under medical expense plan.
16. for orthodontia, unless included by rider.
17. prior to the date the Insured is covered under the Plan.
18. for the diagnosis or treatment of TMJ
19. for hospital services.
20. for any unmarried child age 19 years of age and over unless he is dependent upon You for support, while a full-time student. A full-time student is one who is enrolled for 12 semester hours for credit in an accredited junior college, college or university. Any exception for a full-time student will end at age 23.
21. during any waiting period We require, when You voluntarily end Your insurance and re-enroll at a later date. Your waiting period is 2 years and begins on the date Your coverage first ended.