|Benefits / Limitations
|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
|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
|Cleanings and Fluoride.
|One per calendar year per member. Fluoride treatment requires prior authorization.
|The treatment of tooth decay by the use of silver and/ white fillings.
|Fillings are covered once per two years for the same tooth surface.
|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 once per five year. 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 Client per lifetime limitation. Certain conditions must be met. Prior authorization is required.
|The treatment of the supporting tissues of the teeth, gums, and underlying bone, with either surgical or non-surgical procedures (where applicable).
|Limited Benefit (Gingivoplasty and gingivectomy only)
|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.
|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.
|Single crowns – covered benefit; one time every 5 years per tooth
Fixed bridgework not a covered benefit
Implants – not a covered benefit
|The extraction, either simple or surgical, of either a single tooth or multiple teeth.
|Covered for all permanent, baby and extra teeth.
|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.
|The surgical removal of fully erupted teeth when medically necessary or teeth partially or fully covered by gum tissue or bone.
|Requires prior authorization.