Your Covered CT Dental Benefits

Care CategoryDescriptionBenefits / Limitations
DiagnosticOral 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
1 every 3 years
PreventionCleanings 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.

PeriodonticsThe 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
ExtractionsThe extraction, either simple or surgical, of either a single tooth or multiple teeth.Covered for all permanent, baby and extra teeth.
Oral SurgeryThe 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 ExtractionsThe surgical removal of fully erupted teeth when medically necessary or teeth partially or fully covered by gum tissue or bone.Requires prior authorization.
updated 6/1/22 Subject to change.