Diagnostic |
Initial oral exam |
Once per dentist per 60 months |
100% |
Periodic oral exam |
Twice per plan year |
100% |
Full mouth X-rays |
Once every 60 months |
100% |
Bitewing X-rays |
Twice per plan year |
100% |
Single tooth X-rays |
As needed |
100% |
Preventive |
Routine cleaning |
Twice per plan year |
100% |
Fluoride varnish application |
Children under 19 – Twice per plan year |
100% |
Topical fluoride treatment |
Children under 19 – Twice per plan year |
100% |
Space maintainers |
Only for children under age 14 and not for the replacement of primary or permanent front teeth |
100% |
Sealants |
Sealants on unrestored permanent molars, once per tooth for children under 16 |
100% |
Restorative |
Silver fillings |
Once every two years per surface per tooth |
50% |
White fillings (front teeth) |
Once every two years per surface per tooth |
50% |
Temporary fillings |
Once per tooth |
50% |
Stainless steel crowns |
Under age 15 – One per tooth in 60 months |
50% |
Major Restorative |
Crowns and onlays |
Once per tooth every five years |
30% |
Replacement crowns |
Once every 60 months per tooth |
30% |
Implants |
Once per tooth per 60 months |
30% |
Endodontics |
Root canal treatment |
Once per tooth |
30% |
Vital pulpotomy |
Limited to deciduous teeth |
30% |
Periodontics |
Periodontal cleaning |
Must meet periodontal guidelines |
30% |
Scaling and root planing |
Once per quadrant per 24 months |
30% |
Periodontal surgery |
Must meet periodontal guidelines |
30% |
Dentures and Bridges |
Complete or partial dentures |
Once every 60 months |
30% |
Fixed bridges |
Once every 60 months |
30% |
Replacement dentures or fixed bridges |
Once every 60 months |
30% |
Rebase or reline dentures |
Once every 36 months |
50% |
Repair of dentures or fixed bridges |
Once every 12 months |
50% |
Adding teeth to existing dentures |
Once per tooth |
50% |
Recementing fixed bridges |
Once every 12 months |
50% |
Oral Surgery |
Simple extractions |
Once per tooth |
50% |
Surgical extractions |
Once per tooth |
30% |
Emergency Dental Care |
Minor treatment – pain relief |
Three occurrences in six months |
50% |
Anesthesia |
General anesthesia |
Allowed with covered surgical services only |
50% |