| 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 |
| Prevention | Cleanings and Fluoride. | One per calendar year per member. Fluoride treatment requires prior authorization. |
| Restorative (Fillings) | 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. |
| 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 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. |
| Periodontics | 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) |
| 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 (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. | Single crowns – covered benefit; one time every 5 years per tooth Fixed bridgework not a covered benefit Implants – not a covered benefit |
| 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. |
| Surgical Extractions | The surgical removal of fully erupted teeth when medically necessary or teeth partially or fully covered by gum tissue or bone. | Requires prior authorization. |
