| Cover Page | 04/28/2025 |
| Individual - Table of Contents | 05/07/2025 |
| Group - Table of Contents | 03/30/2016 |
| Definitions | 04/28/2025 |
| How This Coverage Works (Introduction, Selecting a Primary Care Dentist, Preauthorization, Medically Necessary) | 04/28/2026 |
| Access to Care and Transitional Care (Referrals, Specialty Care Provider as a PCD) | 06/10/2026 |
| Cost-Sharing Expenses and Allowed Amount | 04/28/2026 |
| Individual - Who Is Covered (Eligibility) (pediatric only coverage) | 04/23/2024 |
| Individual - Who Is Covered (Eligibility) | 04/28/2025 |
| Group - Who Is Covered (Eligibility) (pediatric only coverage) | 04/23/2024 |
| Group - Who Is Covered (Eligibility) | 04/28/2025 |
| Pediatric Dental | 04/28/2026 |
| Exclusions | 04/15/2021 |
| Claim Determinations | 04/23/2024 |
| Grievance | 04/15/2021 |
| Utilization Review | 05/28/2021 |
| External Appeal | 03/30/2016 |
| Coordination of Benefits (Group Only) | 03/30/2016 |
| Termination | 04/28/2026 |
| Extension of Benefits | 03/30/2016 |
| Continuation (Group Only) | 03/30/2016 |
| Temporary Suspension Rights for Members of the Armed Forces (Individual Only) | 03/30/2016 |
| General Provisions (Incontestability, Legal Actions, Subrogation, Unilateral Modification) | 04/28/2026 |
| Schedule of Benefits | 05/21/2025 |
| Domestic Partner Rider (Group Only) | 04/15/2020 |
| Adult Dental Care | 04/23/2024 |
| Standard Adult Dental Care | 04/28/2025 |
| Standard Adult Cost-Sharing Expenses and Allowed Amount | 04/28/2025 |
| Standard Adult Schedule of Benefits | 04/28/2026 |
