Covered Dental Services

Covered dental services are organized into the following categories:

Diagnostic Services

• One complete initial oral exam, including initial dental history and charting of the teeth and supporting structures
• Single tooth x-rays as needed
• Bitewing x-rays of the crowns of the teeth (once each six months)
• Full mouth x-rays (seven or more films, or panoramic x-ray with bitewing x-rays; once each 60 months)
• Study models and casts used in planning treatment (once each 60 months)
• Emergency exams
• Periodic or routine oral exams (twice each calendar year)

Preventive Services

• Routine cleaning, scaling, and polishing of the teeth (twice each calendar year)
• Fluoride treatment for members under age 19 (twice each calendar year)
• Space maintainers required due to premature loss of teeth for members under age 19
• Sealants applied to permanent premolar and molar surfaces for members under age 14 (one application each 48 months for each premolar or molar surface)

Basic Restorative Services

• Amalgam (silver) fillings (limited to one filling for each tooth surface in each 12 months). No benefits are provided for fillings on tooth surfaces where a sealant was applied within the last 12 months.
• Composite resin (tooth color) fillings on front teeth (limited to one filling for each tooth surface in each 12 months). These benefits include single-surface composite resin fillings on back teeth.
• Pin retention for fillings
• Stainless steel crowns on primary (baby) teeth
• Stainless steel crowns on first permanent (adult) molars for members under age 16

Prosthetic Maintenance

• Repair of partial or complete dentures, crowns, and bridges (once each 12 months)
• Adding teeth to an existing partial or complete denture
• Rebase or reline dentures (once each 36 months)
• Re-cementing of crowns, inlays, onlays and fixed bridgework (once each 12 months)

Other Covered Services

• Occlusal adjustments (once each 24 months)
• Services to treat root sensitivity
• General anesthesia when administered in conjunction with covered surgical services
• Emergency dental treatment to relieve acute pain

Major Restorative Services

• Oral Surgery
• Tooth extractions
• Root removal
• Biopsies
• Periodontics (Gum and Bone)
• Periodontal scaling and root planning (once in each quadrant each 24 months)
• Periodontal surgery (soft and hard tissue surgeries; once in each quadrant each 36 months)
• Periodontal maintenance following active periodontal therapy (once each three months)
• Endodontics (Root and Pulp)
• Root canal therapy on permanent teeth (once in a lifetime for each tooth)
• Retreatment root canal therapy on permanent teeth (once in a lifetime for each tooth)
• Therapeutic pulpotomy on primary or permanent teeth for members under age 16
• Other endodontic surgery intended to treat or remove the dental root

Prosthodontics (Tooth Replacement)

• Complete or partial dentures, including services to fabricate, measure, fit, and adjust them (once each 60 months for each arch)
• Fixed bridges, including services to fabricate, measure, fit, and adjust them (once each 60 months for each tooth)
• Replacement of dentures and bridges, but only when they are installed at least 60 months after the initial placement, and only if the existing appliance cannot be made serviceable
• Temporary partial dentures to replace any of the six upper or lower front teeth, but only if they are installed immediately following the loss of teeth and during the period of healing

Major Restorative Services (Crowns, Inlays and Onlays)

• Crowns for members age 16 or older once each 60 months for each tooth. Note, these benefits include single-tooth dental endosteal implants (the fixture and abutment portion) when the implant replaces permanent teeth through the second molars (once each 60 months for each tooth).
• Metallic, porcelain and composite resin inlays for members age 16 or older
• Metallic, porcelain and composite resin onlays for members age 16 or older (once each 60 months for each tooth)
• Replacement of crowns for members age 16 or older (once each 60 months for each tooth)
• Replacement of metallic, porcelain and composite resin inlays (once each 60 months for each tooth)
• Replacement of metallic, porcelain and composite resin onlays for members age 16 or older (once each 60 months for each tooth)
• Post and core or crown buildup for members age 16 or older (once each 60 months for each tooth)

Orthodontics

Orthodontic benefits, including braces and related services during treatment, are provided for adults and children.

Emergency Care

The plan defines “emergency treatment” as treatment needed to immediately alleviate pain or infection or to treat an injury. Emergency treatment is covered as a basic restorative service, regardless of where it is provided. Emergency treatment does not include any final restorations (i.e., root canal, crowns, and dentures).