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Class I Benefits – Preventive Services
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- Diagnostic and Preventive Services: Services and procedures to evaluate existing conditions and/or to prevent dental abnormalities or disease. These services include examinations, prophylaxes, and fluoride treatments.
- Emergency Palliative Treatment: Emergency treatment to temporarily relieve pain.
- Radiographs: X-rays as required for routine care or as necessary for the diagnosis of a specific condition.
- Recement Crowns.
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Class II Benefits – Basic Services
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- Endodontic Services: The treatment of teeth with diseased or damaged nerves (for example, root canals). Excludes apicoectomy.
- Minor Restorative Services: Minor services to rebuild and repair natural tooth structure when damaged by disease or Injury. Minor restorative services include amalgam (silver) and resin (white) fillings.
- Emergency and Specialty Exams.
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Class III Benefits – Major Services
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- Oral Surgery Services: Extractions and dental surgery, including preoperative and postoperative care.
- Periodontic Services: The treatment of diseases of the gums and supporting structures of the teeth. This includes periodontal maintenance following active therapy (periodontal prophylaxes). Actisite is a covered benefit.
- Relines and Repairs: Relines and repairs to crowns, bridges, partial dentures, and complete dentures.
- Major Restorative Services: Services to rebuild and repair natural tooth structure when damaged by disease or Injury, such as crowns, used when teeth cannot be restored with another filling material.
- Prosthodontic Services: Services and appliances that replace missing natural teeth (such as bridges, partial dentures, and complete dentures).
- Veneers – Labial Veneers – (cosmetic bonding).
- Apicoectomy – Periradicular Surgery.
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- Dental Anesthesia: Dental anesthesia is payable at 50%, subject to the deductible and calendar year maximum. General anesthesia/IV sedation is a covered charge only if there is demonstrated medical need, including the following:
- Toxicity to local anesthetic,
- Severe disability, spastic or severe behavioral problems,
- Prolonged or severe surgical procedure (includes removal of impacted tooth-soft tissue, removal of impacted tooth – partial bony, removal impacted tooth – completely bony impacted, surgical removal of residual tooth roots (cutting procedure),
- Extractions in two or more quadrants,
- Acute infection around the injection site,
- Failure of local anesthesia to control pain, or
- Subject is under four years of age.
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