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WHAT IS COVERED

Covered Dental Services

The following services or supplies shall be eligible under the Plan, subject to the limitations and exclusions listed in the limitations section. Further, for a service to be covered:

  • It must be a covered expense as listed in this Plan; its provision must not be excluded as provided in this Plan; its cost must not exceed the aggregate amount available for such service as provided in this Plan; and it must be obtained in accordance with all the terms, policies and procedures provided for such service or supply in this Plan.
  • The service or supply must be provided while coverage under this Plan is in effect.
  • The services and supplies must be Medically Necessary. Dental services or supplies will be considered Medically Necessary if they meet all of the following conditions: (1) they are provided by a licensed provider who is qualified to perform the service or to provide the supply; (2) the provider exercises prudent clinical judgment in selecting the service or supply for the purpose of preventing, evaluating, diagnosing or treating an illness, injury, disease or its symptoms in the judgment of the Claims Administrator and the service or supply must meet the following conditions in the judgment of the Claims Administrator:
    • It must be provided in accordance with generallyaccepted standards of dental practice;
    • It must be clinically appropriate in terms of type, frequency, extent, site and duration, and it must be considered effective for the patient’s illness, injury or disease;
    • It must not have been provided primarily for the convenience of the patient, the physician or dental provider or other health care provider; and
    • It must not be more costly than an alternative service or sequence of services that would likely have produced an equivalent therapeutic or diagnostic result in light of the patient’s illness, injury or disease.

Covered Dental Services Under This Plan
Diagnostic and Preventitive Care
Office Visits
  • Routine comprehensive or recall examination – limited to 2 visits in a 12-month period
  • Problem-focused examination – limited to 2 visits in a 12-month period
  • Prophylaxis (adult or child treatment during office visit) – limited to 2 treatments in a 12-month period
  • Topical application of fl uoride – limited to 1 course of treatment in a 12-month period and limited to treatment of children under age 16
  • Sealants (per tooth) – limited to 1 application every 36 months on permanent molars only and limited to treatment of children under age 16
X-Rays
  • Periapical x-rays – single films up to a total of 13 films per visit
  • Bitewing x-rays – limited to 2 sets in a calendar year
  • Complete x-ray series, including bitewings, if necessary, or panoramic film – limited to 1 set every 36 months
  • Vertical bitewing x-rays – limited to 1 set every 36 months
Space Maintainers Only covered when needed to preserve space resulting from premature loss of primary teeth. The procedure includes all adjustments which occur within 6 months of the installation.
  • Only covered when needed to preserve space resulting from premature loss of primary teeth. The procedure includes all adjustments which occur within 6 months of the installation.
  • Removable unilateral or bilateral space maintainers
Basic Restorative Care
Visits
  • Professional visits after hours – payment will be based upon the greater of the service rendered or the visit charge
  • Emergency palliative treatment – paid per visit
X-Ray and Pathology
  • Intra-oral, occlusal view, maxillary or mandibular
  • Upper or lower jaw, extra-oral
  • Biopsy and histopathologic examination of oral tissue
Oral Surgery
  • Extractions – erupted tooth or exposed root
  • Extractions – coronal remnants
  • Extractions – surgical removal of erupted tooth/root tip
  • Impacted teeth – removal of tooth (soft tissue)
  • Odontogenic cysts and neoplasms – incision and drainage of abscess
  • Odontogenic cysts and neoplasms – removal of odontogenic cysts or tumor
Other surgical procedures
  • Alveoplasty, in conjunction with extractions – per quadrant
  • Alveoplasty, in conjunction with extractions, 1 to 3 teeth or tooth spaces – per quadrant
  • Alveoplasty, not in conjunction with extractions – per quadrant
  • Alveoplasty, not in conjunction with extractions, 1 to 3 teeth or tooth spaces – per quadrant
  • Sialolithotomy: removal of salivary calculus
  • Closure of salivary fistula
  • Excision of hyperplastic tissue
  • Removal of exostosis
  • Transplantation of tooth or tooth bud
  • Closure of oral fistula of maxillary sinus
  • Sequestrectomy
  • Crown exposure to aid eruption
  • Removal of foreign body from soft tissue
  • Frenectomy
  • Suture of soft tissue injury
Periodontics
  • Occlusal adjustments (other than with an appliance or by restoration)
  • Root planing and scaling, per quadrant – limited to 4 separate quadrants every 24 months
  • Root planing and scaling, 1 to 3 teeth per quadrant – limited to 1 per site every 24 months
  • Gingivectomy, per quadrant – limited to 1 per quadrant every 36 months
  • Gingivectomy, 1 to 3 teeth per quadrant – limited to 1 per site every 36 months
  • Gingival flap procedure, per quadrant – limited to 1 per quadrant every 36 months
  • Gingival flap procedure, 1 to 3 teeth per quadrant – limited to 1 per site every 36 months
  • Periodontal maintenance procedures following active therapy shall be limited to 2 procedures in a 12-month period
  • Localized delivery of antimicrobial agents
Endodontic
  • Pulp capping
  • Pulpotomy
  • Apexification/recalcification
  • Apicoectomy
  • Root canal therapy, including necessary x-rays – anterior or bicuspid
Restorative dentistry Excluding inlays, crowns (other than prefabricated stainless steel or resin) and bridges. Multiple restorations in 1 surface will be considered one restoration.
  • Amalgam restoration
  • Resin-based composite restorations (other than for molars)
  • Pins – pin retention, allowed per tooth in addition to amalgam or resin restoration
  • Crowns when tooth cannot be restored with a filling material – including prefabricated stainless steel or prefabricated resin crown (excluding temporary crowns)
  • Recementation including inlay, crown and bridge
Major Restorative Care
Oral Surgery
  • Removal of impacted teeth (partially bony)
  • Removal of impacted teeth (completely bony)
Periodontics
  • Osseous surgery, including flap and closure, 1 to 3 teeth per quadrant, limited to 1 site,in a 36 month period
  • Osseous surgery, including flap and closure, limited to 1 per quadrant, in a 36 month period
  • Soft-tissue graft procedures
  • Clinical crown lengthening, hard tissue
  • Full mouth debridement, limited to once every 36 months
Endodonic
  • Root canal therapy, including necessary x-rays
  • Molar root canal therapy, including necessary x-rays
Restorative This category includes inlays, onlays, labial veneers and crowns only when they are employed as treatment for decay or acute traumatic injury and only when teeth cannot be restored with a filling material or when the tooth is an abutment to a fixed bridge (limited to 1 per tooth every 5 years [see replacement rule])
  • Inlays/Overlays
  • Labial veneers
    • Laminate – chairside
    • Resin laminate – laboratory
    • Porcelain laminate – laboratory
  • Crowns
    • Resin
    • Resin with noble metal
    • Resin with base metal
    • Porcelain/ceramic substrate
    • Porcelain with noble metal
    • Porcelain with base metal
    • Base metal (full cast)
    • Noble metal (full cast)
    • 3/4 cast metallic or porcelain/ceramic
  • Post and core
  • Core buildup, including any pins
Prosthodontics The first installation of dentures and bridges is covered only if needed to replace teeth extracted while coverage was in force and which were not abutments to a denture or bridge fewer than 5 years old. [See the Plan’s Tooth Missing but not Replaced Rule.] Replacement of existing bridges or dentures will be covered no more frequently than once every 5 years. [See the Plan’s Replacement Rule.]
  • Bridge abutments (See Inlays and Crowns)
  • Pontics
    • Base metal (full cast)
    • Noble metal (full cast)
    • Porcelain with noble metal
    • Porcelain with base metal
    • Resin with noble metal
    • Resin with base metal
  • Removable bridge (unilateral) – one-piece casting, chrome cobalt alloy clasp attachment (all types) per unit, including pontics
  • Dentures and partials – fees for dentures and partial dentures include relines, rebases and adjustments within 6 months after installation. Fees for relines and rebases include adjustments within 6 months after installation. Specialized techniques and characterizations are not eligible
    • Complete upper denture
    • Complete lower denture
    • Partial upper or lower, resin base (including any conventional clasps, rests and teeth)
    • Stress breakers
    • Interim partial denture (stayplate), anterior only
    • Office reline
    • Laboratory reline
    • Special tissue conditioning, per denture
    • Rebase, per denture – adjustments to denture more than 6 months after installation
  • Full and partial denture repairs
    • Broken denture, no teeth involved
    • Repair cast framework
    • Replacing missing or broken teeth, each tooth
    • Adding teeth to existing partial denture – each tooth and each clasp
  • Repairs:crowns and bridges
  • Occlusal guard (for bruxism only), limited to 1 every 36 months
General anesthesia and intensive sedation Only when Medically Necessary and only when provided in conjunction with a covered surgical procedure
Orthodontic Care
Interceptive orthodontic treatment
Limited orthodontic treatment
Comprehensive orthodontic treatment of adolescent dentition
Post-treatment stabilization
Removable appliance therapy to control harmful habits
Fixed-appliance therapy to control harmful habits
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