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|ADA Code||Description||Permanent Amount||Primary Amount|
THIS IS NOT A GUARANTEE OF PAYMENT
The benefits are subject to a waiting period, as shown in the policy schedule, and the provisions in the Limitations and Exclusions section. Specific benefits are subject to a Policy Year maximum per covered person. The benefits are listed per covered person. All treatments must be performed by a Dentist. Policy must be in force and considered current when claim is submitted.