| Care Category | Description | Benefits / Limitations |
|---|---|---|
| Diagnostic | Oral examination or screening every calendar year. |
Periodic Exam: 1 per year Problem Focused Exam: 4 times per year Comprehensive Exam: limited to once per lifetime |
X-Rays |
Complete mouth X-rays, periapical X-rays, bitewing X-rays, Occlusal X-rays and panoramic X-rays. | Bitewing X-ray: 1 per year Periapical X-rays: 4 per year Complete Mouth Series or Panoramic X-ray: 1 every 3 years |
| Preventive | Cleaning and fluoride application. | One per calendar year per member. Fluoride treatment requires prior authorization. |
| Restorative (Fillings) | The treatment of tooth decay by the use of silver and/or white fillings. | Fillings are covered once per two years for the same tooth surface. |
| Restorative (Crowns) | The use of gold, semiprecious, or nonprecious metals and/or porcelain to restore a tooth or teeth which cannot be restored with silver or white restorations. Covered CT covers only non-precious metals; and porcelain fused to predominantly base metal for anterior teeth. | Covered once per five years. Prior authorization required. |
| Endodontic (Root Canal) | The treatment of the diseases of the blood vessels and the nerve of the tooth. Endodontic treatment often involves root canal procedures. | Once per tooth per Member per lifetime limitation. Certain conditions must be met. Prior authorization is required. |
| Periodontics | The treatment of the supporting tissues of the teeth, gums, and underlying bone, with either surgical or non-surgical procedures (where applicable). | Prior authorization required. |
| Prosthetics (Removable) | The replacement of missing teeth by the use of a removable appliance. |
Denture prosthesis construction is limited to one time per each 7-year period. Prior authorization required. |
| Prosthetics (Adjustments and Relines) |
The repair or modification of existing dentures so that they can continue to be serviceable. | Limited to once every 2 years, and only 6 months after initial placement of the denture(s). |
| Prosthetics (Fixed) | The use of gold, semiprecious, or precious metal to replace a missing tooth or teeth. Fixed prosthetics may include bridgework, implants and implant retained crowns and dentures. | Not a covered service. |
| Extractions | The extraction, either simple or surgical, of either a single tooth or multiple teeth. | Covered for all permanent, baby and extra teeth. |
| Oral Surgery | The use of surgery for the shaping of bone ridges, the treatment of an abscess, biopsies of soft and hard tissues, reconstructive surgeries etc. | Biopsies, bone grafting, alveoloplasty, facial surgery for trauma and inherited facial conditions. Prior authorization is required. |
| Wisdom Tooth Removal and Impactions |
The surgical removal of fully erupted teeth when medically necessary or teeth partially or fully covered by gum tissue or bone. | Requires prior authorization. |
| Orthodontics | The straightening of teeth for significant dental health reasons. | Not covered for adults. |
| Athletic Mouth Guard | Mouthguards are worn over the top row of teeth during sports to help prevent an oral injury. They protect against broken teeth, cut lips, and other damage to the mouth. | Not covered for adults. |
| Occlusal “Night Guards | A removable acrylic appliance intended to relieve temporomandibular joint pain and other effects of grinding the teeth (bruxism). Usually worn at night to prevent grinding during sleep. | Prior Authorization required for members with severe clenching or tooth grinding habits. May be used to treat temporomandibular joint (TMJ) problems. |
| Deep Sedation-General Anesthesia | Covered for general dental procedures and tooth extractions in children under the age of 9 OR for children under the age of 21 with behavioral related conditions such as autism, cerebral palsy, intellectual delays. | Covered in certain situations. |
| Inhalation Sedation | Nitrous oxide. Covered for adults over the age of 21 with behavioral related conditions such as autism, cerebral palsy, intellectual delays and have a diagnosis of 318.0 or greater | Not covered for adults without a severe or profound developmental delay. |
For Covered CT Members Ages 19 and 20
Additional benefits include preventive services once every 6 months, orthodontics once per lifetime,
and athletic mouth guards subject to prior authorization and frequency limitations.
Call 855-CT-DENTAL (855-283-3682)
to get more information.
updated 6/1/22 and 10/7/24. Subject to change.
