Diagnostic |
Comprehensive oral exam |
Under age 19 – once every 6 months
Age 19 and over – once every 60 months |
100% |
Periodic oral exam |
Once every six months |
100% |
Full mouth X-rays |
Once every 60 months |
100% |
Bitewing X-rays |
Once every six months |
100% |
Single tooth X-rays |
As needed |
100% |
Study models and casts |
Under age 19 – Once every 60 months |
100% |
Preventive |
Routine cleaning |
Once every six months |
100% |
Fluoride varnish application |
Under age 19 – Two every 12 months |
100% |
Topical fluoride treatment |
Under age 19 – Two every 12 months |
100% |
Space maintainers |
Only for children under age 19 and not for the replacement of primary or permanent front teeth |
100% |
Sealants |
Under age 19 – One sealant per tooth every 36 months |
100% |
Restorative |
Silver fillings |
Covered |
80% |
White fillings (front teeth) |
Covered |
80% |
Temporary fillings |
Once per tooth |
80% |
Stainless steel crowns |
Under age 19 – One per tooth in 60 months |
80% |
Major restorative |
Crowns |
When teeth cannot be restored with fillings |
50% |
Replacement crowns |
Once every 60 months |
50% |
Implants |
Under age 19 – covered
Age 19 and over – not covered |
50% |
Endodontics |
Root canal treatment |
Covered |
50% |
Vital pulpotomy |
Limited to baby teeth |
50% |
Periodontics |
Periodontal cleaning |
Under age 19 – Four in 12 months
Age 19 and older – One per 3 months |
80% |
Scaling and root planing |
Subject to periodontal guidelines |
50% |
Periodontal surgery |
Must meet periodontal guidelines |
50% |
Dentures and bridges |
Complete or partial dentures |
Once every 60 months |
50% |
Fixed bridges |
Once every 60 months |
50% |
Replacement dentures or fixed bridges |
If they cannot be made serviceable once every 60 months |
50% |
Rebase or reline dentures |
Once every 36 months |
80% |
Repair of dentures or fixed bridges |
Once every 12 months |
80% |
Adding teeth to existing dentures |
Covered |
80% |
Recementing fixed bridges |
Once every 12 months |
80% |
Oral surgery |
Simple extractions |
Covered |
80% |
Surgical extractions |
Under 19 – Covered |
80% |
Age 19 and over – Covered |
50% |
Orthodontics |
Orthodontia |
Under age 19 – When medically necessary |
50% |
Emergency dental care |
Minor treatment - pain relief |
Under age 19 – Covered |
100% |
Age 19 and older – Covered |
80% |
Anesthesia |
General anesthesia |
Allowed with covered surgical services only |
80% |