Class I Benefits – Preventive Services

  • 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.

Class II Benefits – Basic Services

  • 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.

Class III Benefits – Major Services

  • 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.


  • 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.