Covered Dental Services

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) and surgical exposure impacted/unerupted teeth for orthodontia purposes,
     
  • 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.

Class IV Benefits – Orthodontic Services

• Orthodontic Services (to age 19): Services, treatment, and procedures to correct malposed teeth. If your Eligible Dependent begins receiving Orthodontic services under an Orthodontic treatment plan before reaching age 19, benefits for Orthodontic services under that treatment plan will continue after your Eligible Dependent reaches age 19 until he or she no longer meets the definition of Eligible Dependent, subject to the limitations in the Schedule of Benefits.