Dental Insurance

¹ Endodontics and nonsurgical and surgical periodontics may be included under basic services for some plans.

AFLAC DENTAL – QN81000 SERIES

Aflac dental insurance products will be underwritten by American Family Life Assurance Company of Columbus. Aflac WWHQ | 1932 Wynnton Road | Columbus, GA 31999.

In New York, coverage will be underwritten by American Family Life Assurance Company New York. 22 Corporate Woods Boulevard, Suite 2 | Albany, New York 12211.

This is a brief product overview only. Coverage may not be available in all states. Benefits/premium rates may vary based on state and plan levels. Please see coverage documentation applicable to your situs state for further details.

Optional riders may be available at an additional cost. Certificate and riders may also contain a waiting period. Refer to the exact certificate and rider forms for benefit details, definitions, limitations and exclusions.

NOTICE: The coverage offered is not a qualified health plan (QHP) under the Patient Protection and Affordable Care Act (ACA) and is not required to satisfy essential health benefits mandates of the ACA. The coverage provides limited benefits.

Applies to Policy Series QN81000. In Arkansas, policy form QN81100MAR. In Idaho, QN81100MID. In New York, policy form NYQN81100M. In Oklahoma, policy form QN81100MOK. In Oregon, policy form QN81100MOR and QN81100MORS. In Pennsylvania, QN81100MPA.

Arizona Limitations and Exclusions

We will not pay benefits if you fail to cooperate with our investigation into the validity of your claim. No benefits are payable under the policy for the services listed below. In addition, the services listed below will not be recognized toward the satisfaction of any deductible:

• Any services which are not included in the Schedule of Covered Procedures;
• Any service started or appliance installed before the effective date or after the date coverage terminates, except as provided in the “takeover of existing coverage” section of the certificate;
• Any service, which may not reasonably be expected to successfully correct the patient’s dental condition for a period of at least three years, as determined by us;
• Any procedure we determine is not necessary, does not offer a favorable prognosis, does not have uniform professional endorsement or is experimental in nature;
• Crowns, inlays, onlays, cast restorations, or other laboratory prepared restorations on teeth, which may be satisfactorily restored with an amalgam or composite resin filling;
• Any treatment which is elective or primarily cosmetic in nature and not generally recognized as a generally accepted dental practice by the American Dental Association, as well as any replacement of prior cosmetic restorations unless such procedure is listed in the Schedule of Covered Procedures;
• Appliances, services or procedures relating to: (1) the change or maintenance of vertical dimension; (2) restoration of occlusion (unless otherwise noted in the schedule of covered procedures— only for occlusal guards); (3) splinting; (4) correction of attrition, abrasion, erosion or abfraction; (5) bite registration or (6) bite analysis;
• Replacement of bridges unless the bridge is older than the age allowed in the Schedule of Covered Procedures and cannot be made serviceable;
• Replacement of full or partial dentures unless the prosthetic appliance is older than the age allowed in the Schedule of Covered Procedures and cannot be made serviceable;
• Replacement of crowns, inlays or onlays unless the prior restoration is older than the age allowed in the Schedule of Covered Procedures and cannot be made serviceable;
• For orthodontic treatment unless otherwise listed as a covered procedure in the Schedule of Covered Procedures;
• Services provided for any type of temporomandibular joint (TMJ) dysfunctions, muscular, skeletal deficiencies involving TMJ or related structures, myofascial pain unless such procedure is listed as a covered procedure in the Schedule of Covered Procedures;
• Charges for implants of any type, and all related procedures, removal of implants, precision or semi-precision attachments, denture duplication, overdentures and any associated surgery, or other customized services or attachments unless such procedures are listed as covered procedures in the Schedule of Covered Procedures;
• Athletic mouth guards; myofunctional therapy; treatment for malignancies, cysts and neoplasms; failure to keep scheduled appointment; charges for completion of claim forms;
infection control; precision or semi-precision attachments; denture duplication; oral hygiene instruction; separate charges for acid etch; charges for travel time; transportation costs; professional advice; treatment of jaw fractures; orthognathic surgery; exams required by a third party other than us; personal supplies (e.g., waterpik, toothbrush, floss holder, etc.); or replacement of lost or stolen appliances;
• Prescription drugs, premedication, pharmaceuticals, or analgesia;
• Dental disease, defect or injury caused by a declared or undeclared war or any act of war or terrorism or or taking part in an insurrection or riot; the commission or attempted commission of a crime; an intentionally self-inflicted injury or attempted suicide while sane or insane;
• Dental treatment not approved by the American Dental Association or which is clearly experimental in nature;
• Any charge for a service for which benefits are available under Worker’s Compensation or an Occupational Disease Act or Law, even if the insured person did not purchase the coverage that is available to him;
• Any charge for a service performed outside of the United States other than for emergency treatment. Benefits for emergency treatment performed outside of the United States are limited to a maximum of $100 per year;
• The initial placement of a removable full denture or a removable partial denture unless it includes the replacement of a functioning natural tooth extracted while the person is insured under the policy;
• The initial placement of a fixed partial denture including a Maryland bridge, unless it includes the replacement of a functioning natural tooth extracted while the person is insured under the policy, provided that tooth was not an abutment to an existing partial denture that is less than five years old or to an existing fixed partial denture or Maryland bridge which is less than seven years old or other frequency limitation as stated in Schedule of Covered Procedures. Benefits are payable only for the replacement of those teeth which were extracted while the person was insured under the policy;
• The replacement of teeth beyond the normal complement of 32;
• The replacement of an existing removable partial denture with a fixed partial denture unless upgrading to a fixed partial denture is essential to the correction of the insured person’s dental condition;
• Local anesthetic as a separate fee;
• Any treatment plan which involves full-mouth reconstruction by the removal and reestablishment of occlusal contacts of 10 or more teeth with restorations, crowns, onlays, inlays, fixed partial dentures, dentures, or any combination of these services; and
• Any services (except emergency treatment with a covered procedure or a covered procedure performed in a limited access area) provided by a non-participating provider, if the policyholder has selected an in-network only plan.

Orthodontic Limitations

• If orthodontic treatment continues after the maximum lifetime benefit has been paid, no further benefits will be paid.
• Orthodontic services must begin while the plan is in force. No payments will be made for orthodontic treatment if the appliances or bands are inserted prior to becoming insured except as provided in the takeover of existing coverage provision.
• We consider orthodontic treatment to be started on the date the bands or appliances are inserted. Any other orthodontic treatment that can be completed on the same day it is rendered is considered to be started and completed on the date the orthodontic treatment is rendered.
• Orthodontic services for braces or appliances and orthodontic services for clear aligners are not payable for the same insured person.

Idaho Limitations and Exclusions

We will not pay benefits if you fail to cooperate with our investigation into the validity of your claim. No benefits are payable under the policy for the services listed below. In addition, the services listed below will not be recognized toward the satisfaction of any deductible:

• Any services which are not included in the Schedule of Covered Procedures;
• Any service started or appliance installed before the effective date or after the date coverage terminates, except as provided in the “takeover of existing coverage” section of the certificate;
• Any service, which may not reasonably be expected to successfully correct the patient’s dental condition for a period of at least three years, as determined by us;
• Any procedure we determine is not necessary, does not offer a favorable prognosis, does not have uniform professional endorsement or is experimental in nature;
• Crowns, inlays, onlays, cast restorations, or other laboratory prepared restorations on teeth, which may be satisfactorily restored with an amalgam or composite resin filling;
• Except for congenital disease or anomaly of an insured dependent child, any treatment which is elective or primarily cosmetic in nature and not generally recognized as a generally accepted dental practice by the American Dental Association, as well as any replacement of prior cosmetic restorations unless such procedure is listed in the Schedule of Covered Procedures. Congenital disease or anomaly of newborn or newly adopted children is covered under the certificate to the same extent as other conditions requiring similar treatment and services;
• Appliances, services or procedures relating to: (1) the change or maintenance of vertical dimension; (2) restoration of occlusion (unless otherwise noted in the schedule of covered procedures— only for occlusal guards); (3) splinting; (4) correction of attrition, abrasion, erosion or abfraction; (5) bite registration or (6) bite analysis;
• Replacement of bridges unless the bridge is older than the age allowed in the Schedule of Covered Procedures and cannot be made serviceable;
• Replacement of full or partial dentures unless the prosthetic appliance is older than the age allowed in the Schedule of Covered Procedures and cannot be made serviceable;
• Replacement of crowns, inlays or onlays unless the prior restoration is older than the age allowed in the Schedule of Covered Procedures and cannot be made serviceable;
• For orthodontic treatment unless otherwise listed as a covered procedure in the Schedule of Covered Procedures;
• Services provided for any type of temporomandibular joint (TMJ) dysfunctions, muscular, skeletal deficiencies involving TMJ or related structures, myofascial pain unless such procedure is listed as a covered procedure in the Schedule of Covered Procedures;
• Charges for implants of any type, and all related procedures, removal of implants, precision or semi-precision attachments, denture duplication, overdentures and any associated surgery, or other customized services or attachments unless such procedures are listed as covered procedures in the Schedule of Covered Procedures;
• Athletic mouth guards; myofunctional therapy; treatment for malignancies, cysts and neoplasms; failure to keep scheduled appointment; charges for completion of claim forms;
infection control; precision or semi-precision attachments; denture duplication; oral hygiene instruction; separate charges for acid etch; charges for travel time; transportation costs; professional advice; treatment of jaw fractures; orthognathic surgery; exams required by a third party other than us; personal supplies (e.g., waterpik, toothbrush, floss holder, etc.); or replacement of lost or stolen appliances;
• Prescription drugs, premedication, pharmaceuticals, or analgesia;
• Dental disease, defect or injury caused by a declared or undeclared war or any act of war or or taking part in an insurrection or riot; the commission or attempted commission of a crime; an intentionally self-inflicted injury or attempted suicide while sane or insane;
• Dental treatment not approved by the American Dental Association or which is clearly experimental in nature;
• Any charge for a service for which benefits are available under Worker’s Compensation or an Occupational Disease Act or Law, even if the insured person did not purchase the coverage that is available to him;
• Any charge for a service performed outside of the United States other than for emergency treatment. Benefits for emergency treatment performed outside of the United States are limited to a maximum of $100 per year;
• Services performed by a dentist who is a member of the insured person’s family. Insured person’s family is limited to a spouse, siblings, parents, children, grandparents, and the spouse’s siblings and parents;
• The initial placement of a removable full denture or a removable partial denture unless it includes the replacement of a functioning natural tooth extracted while the person is insured under the policy;
• The initial placement of a fixed partial denture including a Maryland bridge, unless it includes the replacement of a functioning natural tooth extracted while the person is insured under the policy, provided that tooth was not an abutment to an existing partial denture that is less than five years old or to an existing fixed partial denture or Maryland bridge which is less than seven years old or other frequency limitation as stated in Schedule of Covered Procedures. Benefits are payable only for the replacement of those teeth which were extracted while the person was insured under the policy;
• The replacement of teeth beyond the normal complement of 32;
• The replacement of an existing removable partial denture with a fixed partial denture unless upgrading to a fixed partial denture is essential to the correction of the insured person’s dental condition;
• Local anesthetic as a separate fee;
• Any treatment plan which involves full-mouth reconstruction by the removal and reestablishment of occlusal contacts of 10 or more teeth with restorations, crowns, onlays, inlays, fixed partial dentures, dentures, or any combination of these services; and
• Any services (except emergency treatment with a covered procedure or a covered procedure performed in a limited access area) provided by a non-participating provider, if the policyholder has selected an in-network only plan.

Orthodontic Limitations

• If orthodontic treatment continues after the maximum lifetime benefit has been paid, no further benefits will be paid.
• Orthodontic services must begin while the plan is in force. No payments will be made for orthodontic treatment if the appliances or bands are inserted prior to becoming insured except as provided in the takeover of existing coverage provision.
• We consider orthodontic treatment to be started on the date the bands or appliances are inserted. Any other orthodontic treatment that can be completed on the same day it is rendered is considered to be started and completed on the date the orthodontic treatment is rendered.
• Orthodontic services for braces or appliances and orthodontic services for clear aligners are not payable for the same insured person.

New Jersey Limitations and Exclusions

We will not pay benefits if you fail to cooperate with our investigation into the validity of your claim. No benefits are payable under the policy for the services listed below. In addition, the services listed below will not be recognized toward the satisfaction of any deductible:

• Any services which are not included in the Schedule of Covered Procedures;
• Any service started or appliance installed before the effective date or after the date coverage terminates, except as provided in the “takeover of existing coverage” section of the certificate;
• Any service, which may not reasonably be expected to successfully correct the patient’s dental condition for a period of at least three years, as determined by us;
• Any procedure we determine is not necessary, does not offer a favorable prognosis, does not have uniform professional endorsement or is experimental in nature;
• Crowns, inlays, onlays, cast restorations, or other laboratory prepared restorations on teeth, which may be satisfactorily restored with an amalgam or composite resin filling;
• Any treatment which is elective or primarily cosmetic in nature and not generally recognized as a generally accepted dental practice by the American Dental Association, as well as any replacement of prior cosmetic restorations unless such procedure is listed in the Schedule of Covered Procedures;
• Appliances, services or procedures relating to: (1) the change or maintenance of vertical dimension; (2) restoration of occlusion (unless otherwise noted in the schedule of covered procedures— only for occlusal guards); (3) splinting; (4) correction of attrition, abrasion, erosion or abfraction; (5) bite registration or (6) bite analysis;
• Replacement of bridges unless the bridge is older than the age allowed in the Schedule of Covered Procedures and cannot be made serviceable;
• Replacement of full or partial dentures unless the prosthetic appliance is older than the age allowed in the Schedule of Covered Procedures and cannot be made serviceable;
• Replacement of crowns, inlays or onlays unless the prior restoration is older than the age allowed in the Schedule of Covered Procedures and cannot be made serviceable;
• For orthodontic treatment unless otherwise listed as a covered procedure in the Schedule of Covered Procedures;
• Services provided for any type of temporomandibular joint (TMJ) dysfunctions, muscular, skeletal deficiencies involving TMJ or related structures, myofascial pain unless such procedure is listed as a covered procedure in the Schedule of Covered Procedures;
• Charges for implants of any type, and all related procedures, removal of implants, precision or semi-precision attachments, denture duplication, overdentures and any associated surgery, or other customized services or attachments unless such procedures are listed as covered procedures in the Schedule of Covered Procedures;
• Athletic mouth guards; myofunctional therapy; treatment for malignancies, cysts and neoplasms; failure to keep scheduled appointment; charges for completion of claim forms; infection control; precision or semi-precision attachments; denture duplication; oral hygiene instruction; separate charges for acid etch; charges for travel time; transportation costs; professional advice; treatment of jaw fractures; orthognathic surgery; exams required by a third party other than us; personal supplies (e.g., waterpik, toothbrush, floss holder, etc.); or replacement of lost or stolen appliances;
• Prescription drugs, premedication, pharmaceuticals, or analgesia;
• Dental disease, defect or injury caused by a declared or undeclared war or any act of war or terrorism or or taking part in an insurrection or riot; the commission or attempted commission of a crime; an intentionally self-inflicted injury or attempted suicide while sane or insane;
• Dental treatment not approved by the American Dental Association or which is clearly experimental in nature;
• Any charge for a service for which benefits are available under Worker’s Compensation or an Occupational Disease Act or Law, even if the insured person did not purchase the coverage that is available to him;
• Any charge for a service performed outside of the United States other than for emergency treatment. Benefits for emergency treatment performed outside of the United States are limited to a maximum of $100 per year;
• Services performed by a dentist who is a member of the insured person’s family. Insured person’s family is limited to a spouse, siblings, parents, children, grandparents, and the spouse’s siblings and parents;
• The initial placement of a removable full denture or a removable partial denture unless it includes the replacement of a functioning natural tooth extracted while the person is insured under the policy;
• The initial placement of a fixed partial denture including a Maryland bridge, unless it includes the replacement of a functioning natural tooth extracted while the person is insured under the policy, provided that tooth was not an abutment to an existing partial denture that is less than five years old or to an existing fixed partial denture or Maryland bridge which is less than seven years old or other frequency limitation as stated in Schedule of Covered Procedures. Benefits are payable only for the replacement of those teeth which were extracted while the person was insured under the policy;
• The replacement of teeth beyond the normal complement of 32;
• The replacement of an existing removable partial denture with a fixed partial denture unless upgrading to a fixed partial denture is essential to the correction of the insured person’s dental condition;
• Local anesthetic as a separate fee;
• Any treatment plan which involves full-mouth reconstruction by the removal and reestablishment of occlusal contacts of 10 or more teeth with restorations, crowns, onlays, inlays, fixed partial dentures, dentures, or any combination of these services; and
• Any services (except emergency treatment with a covered procedure or a covered procedure performed in a limited access area) provided by a non-participating provider, if the policyholder has selected an in-network only plan.

Orthodontic Limitations

• If orthodontic treatment continues after the maximum lifetime benefit has been paid, no further benefits will be paid.
• Orthodontic services must begin while the plan is in force. No payments will be made for orthodontic treatment if the appliances or bands are inserted prior to becoming insured except as provided in the takeover of existing coverage provision.
• We consider orthodontic treatment to be started on the date the bands or appliances are inserted. Any other orthodontic treatment that can be completed on the same day it is rendered is considered to be started and completed on the date the orthodontic treatment is rendered.
• Orthodontic services for braces or appliances and orthodontic services for clear aligners are not payable for the same insured person.

Virginia limitations and exclusions

We will not pay benefits if you fail to cooperate with our investigation into the validity of your claim. No benefits are payable under the policy for the services listed below. In addition, the services listed below will not be recognized toward the satisfaction of any deductible:

• Any services which are not included in the Schedule of Covered Procedures;
• Any service started or appliance installed before the effective date or after the date coverage terminates, except as provided in the “takeover of existing coverage” section of the certificate;
• Any service, which may not reasonably be expected to successfully correct the patient’s dental condition for a period of at least three years, as determined by us;
• Any procedure we determine is not necessary, does not offer a favorable prognosis, does not have uniform professional endorsement or is experimental in nature;
• Crowns, inlays, onlays, cast restorations, or other laboratory prepared restorations on teeth, which may be satisfactorily restored with an amalgam or composite resin filling;
• Any treatment which is elective or primarily cosmetic in nature and not generally recognized as a generally accepted dental practice by the American Dental Association, as well as any replacement of prior cosmetic restorations unless such procedure is listed in the Schedule of Covered Procedures;
• Appliances, services or procedures relating to: (1) the change or maintenance of vertical dimension; (2) restoration of occlusion (unless otherwise noted in the schedule of covered procedures— only for occlusal guards); (3) splinting; (4) correction of attrition, abrasion, erosion or abfraction; (5) bite registration or (6) bite analysis;
• Replacement of bridges unless the bridge is older than the age allowed in the Schedule of Covered Procedures and cannot be made serviceable;
• Replacement of full or partial dentures unless the prosthetic appliance is older than the age allowed in the Schedule of Covered Procedures and cannot be made serviceable;
• Replacement of crowns, inlays or onlays unless the prior restoration is older than the age allowed in the Schedule of Covered Procedures and cannot be made serviceable;
• For orthodontic treatment unless otherwise listed as a covered procedure in the Schedule of Covered Procedures;
• Services provided for any type of temporomandibular joint (TMJ) dysfunctions, muscular, skeletal deficiencies involving TMJ or related structures, myofascial pain unless such procedure is listed as a covered procedure in the Schedule of Covered Procedures;
• Charges for implants of any type, and all related procedures, removal of implants, precision or semi-precision attachments, denture duplication, overdentures and any associated surgery, or other customized services or attachments unless such procedures are listed as covered procedures in the Schedule of Covered Procedures;
• Athletic mouth guards; myofunctional therapy; treatment for malignancies, cysts and neoplasms; failure to keep scheduled appointment; charges for completion of claim forms; infection control; precision or semi-precision attachments; denture duplication; oral hygiene instruction; separate charges for acid etch; charges for travel time; transportation costs; professional advice; treatment of jaw fractures; orthognathic surgery; exams required by a third party other than us; personal supplies (e.g., waterpik, toothbrush, floss holder, etc.); or replacement of lost or stolen appliances;
• Prescription drugs, premedication, pharmaceuticals, or analgesia;
• Dental disease, defect or injury caused by a declared or undeclared war or any act of war or terrorism or or taking part in an insurrection or riot; the commission or attempted commission of a crime; an intentionally self-inflicted injury or attempted suicide while sane or insane;
• Dental treatment not approved by the American Dental Association or which is clearly experimental in nature;
• Any charge for a service for which benefits are available under Worker’s Compensation or an Occupational Disease Act or Law, even if the insured person did not purchase the coverage that is available to him;
• Any charge for a service performed outside of the United States other than for emergency treatment. Benefits for emergency treatment performed outside of the United States are limited to a maximum of $100 per year;
• Services performed by a dentist who is a member of the insured person’s family. Insured person’s family is limited to a spouse, siblings, parents, children, grandparents, and the spouse’s siblings and parents;
• The initial placement of a removable full denture or a removable partial denture unless it includes the replacement of a functioning natural tooth extracted while the person is insured under the policy;
• The initial placement of a fixed partial denture including a Maryland bridge, unless it includes the replacement of a functioning natural tooth extracted while the person is insured under the policy, provided that tooth was not an abutment to an existing partial denture that is less than five years old or to an existing fixed partial denture or Maryland bridge which is less than seven years old or other frequency limitation as stated in Schedule of Covered Procedures. Benefits are payable only for the replacement of those teeth which were extracted while the person was insured under the policy;
• The replacement of teeth beyond the normal complement of 32;
• The replacement of an existing removable partial denture with a fixed partial denture unless upgrading to a fixed partial denture is essential to the correction of the insured person’s dental condition;
• Local anesthetic as a separate fee;
• Any treatment plan which involves full-mouth reconstruction by the removal and reestablishment of occlusal contacts of 10 or more teeth with restorations, crowns, onlays, inlays, fixed partial dentures, dentures, or any combination of these services; and
• Any services (except emergency treatment with a covered procedure or a covered procedure performed in a limited access area) provided by a non-participating provider, if the policyholder has selected an in-network only plan.

Orthodontic Limitations

• If orthodontic treatment continues after the maximum lifetime benefit has been paid, no further benefits will be paid.
• Orthodontic services must begin while the plan is in force. No payments will be made for orthodontic treatment if the appliances or bands are inserted prior to becoming insured except as provided in the takeover of existing coverage provision.
• We consider orthodontic treatment to be started on the date the bands or appliances are inserted. Any other orthodontic treatment that can be completed on the same day it is rendered is considered to be started and completed on the date the orthodontic treatment is rendered.
• Orthodontic services for braces or appliances and orthodontic services for clear aligners are not payable for the same insured person.