Pediatric Dental Amendment

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90NC-1 -21 1 Pediatric Dental Amendment to Your Group Certificate Keep this Amendment with your Group Certificate This Amendment applies to individuals under age 19 who are enrolled in a small employer medical Group Certificate underwritten by HealthPartners Insurance Company. Coverage under this Amendment continues until the end of the month in which the individual turns age 19. Effective Date: The later of the effective date, or most recent anniversary date of the Group Policy and your effective date of coverage under the Group Policy.

• Periodontal splinting. • Athletic mouthguards. • Charges for infection control, sterilization and waste disposal . • Charges for sales tax. • Treatment, procedures, or services or drugs which are provided when you are not covered under this Amendment. • …

  Treatment, Periodontal