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Covered service from a participating provider
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Your share of cost
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Class I Benefits: Diagnostic and Preventive Services (no deductible applies)
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Oral exams
Limited to two in any calendar year.
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$0
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X-rays, full mouth (including bitewing)
Limited to one set in any five-year period.
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$0
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X-rays, bitewing only
Limited to once in any calendar year.
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$0
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Prophylaxis (cleaning, scaling and polishing)
Limited to two in any calendar year, including periodontal prophylaxes. May be performed by a licensed dental hygienist.
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$0
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Fluoride treatments
Limited to children under age 19. Limited to two in any consecutive 12-month period. May be performed by a licensed dental hygienist.
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$0
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Sealants
Limited to occlusal (top biting) surface of first permanent molars for children under age 9 and second permanent molars for children under age 14. Covered once per tooth per lifetime.
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$0
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Emergency palliative treatment (to temporarily relieve pain)
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$0
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Class II Benefits: Basic Services (subject to deductible)
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Oral surgery
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20%
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Minor restorative services, including fillings, relines and repairs to bridges, dentures and partials
Amalgam and resin restorations are payable once within a 24-month period regardless of the number or combination of restorations placed on a tooth surface. Benefits for reline or complete replacement of denture base material are payable once in any three-year period.
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20%
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Periodontics (treatment of the gums and supporting structures of the teeth)
Benefits for root planing are payable once in any two-year period. Periodontal surgery, including subgingival curettage, is payable once in any three-year period.
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$0 for cleaning; 20% for all other services
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Endodontics (root canal therapy)
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20%
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Class III Benefits: Major Restorative Services (subject to deductible)
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Prosthodontics (treatment to replace missing natural teeth or other dental structures)
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50%
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Complete dentures
Limit of one complete upper and one complete lower denture per person in any five-year period.
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50%
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Partial dentures, fixed bridges or removable partials
Limit of one per person in any five-year period except where the loss of additional teeth requires the construction of a new appliance. Fixed bridges and removable cast partials are not covered for children under age 16.
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50%
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Major restorative services, including crowns, jackets and onlays
Treatment per tooth is limited to once in any five-year period. Full porcelain, porcelain/resin processed to metal, full cast or 3/4 cast crowns are not covered for children under age 12.
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50%
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Endosteal implants
An implant for any person can be covered once in any five-year period, per tooth.
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50%
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Class IV Benefits: Orthodontics (no deductible applies)
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Limited to children under age 19. If orthodontia treatment began before coverage under Stryker's healthcare plan became effective, benefits will be calculated based on the remaining months of treatment. If orthodontia treatment is terminated prior to completion, for any reason, benefit payment will end as of the date treatment is terminated. Orthodontics for individuals age 19 and older may be covered if the treatment is determined to be medically necessary.
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50%
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Benefit Maximums
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Class I, Class II and Class III combined
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$2,000 per person per calendar year
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Class IV
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$2,000 per person lifetime maximum
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