9.5 COVERED DENTAL SERVICES
Class I – Diagnostic and Preventive Dental Services:
- Oral examination, limited to two during any calendar year, or Emergency examinations as necessary
- Consultations by a dentist or Physician other than the practitioner providing treatment
- Dental x-rays – One complete mouth x-ray or panoramic x-ray during any period of 3 consecutive years. Benefits are limited to one complete mouth x-ray or one panoramic x-ray, but not both
- Supplementary bitewing x-rays, limited to once every calendar year unless special need is shown
- Intraoral periapical x-rays as needed
- One fluoride treatment per calendar year, limited to Dependent children through age 13 (under 14 years of age)
- Prophylaxis (teeth cleaning), up to twice each calendar year
- Topical application of sealants on permanent teeth, limited to once per tooth per lifetime for Dependent children through age 13 (under 14 years of age)
- Space maintainers, limited to Dependent children through age 13 (under 14 years of age)
- Diagnostic cultures, tests and laboratory examinations
Class II – Basic Dental Services: (subject to the calendar year deductible)
- Restorations (amalgam, silicate, acrylic, synthetic porcelain and composite filling restoration [for anterior teeth only] for decayed or broken teeth)
- Composite filling restoration for posterior teeth are covered at the Usual, Customary, and Reasonable charge for amalgam filling restoration
- Endodontic treatment (root canal therapy, pulp capping)
- Treatment of periodontal disease (maintenance procedures such as scaling and root planning following periodontal surgical services) Note: This benefit is limited to one treatment within any three-month period.
- Extractions and other oral surgical procedures
- General anesthesia as necessary for endodontic, periodontics, and oral surgical procedures
- Stainless steel crowns, limited to Dependent children through age 13 (under 14 years of age)
- Temporary crowns only in the case of emergency for a fractured tooth
- Repair to existing prosthetic appliances, limited to once per calendar year
- Reline or rebase of partial or complete dentures, limited to once per calendar year beginning six months after delivery of a new denture
Class III – Major Dental Services: (subject to the calendar year deductible)
- Inlay/Onlay restorations. Replacement is not covered within 5 years of initial restoration.
- Crowns, including build-up, post and core. Replacement is not covered within 5 years of initial crown-placement.
- Complete or partial dentures, to include the six-month post-delivery care. Replacement is not covered within 5 years of initial denture placement. If the Trust provides benefits for placement of temporary dentures, the benefit otherwise payable for permanent dentures placed within 5 years of the placement of the temporary dentures will be reduced by any benefits paid for the temporary dentures.
- Fixed prosthodontics (bridgework). Replacement is not covered within 5 years of initial placement of bridge-work.
- Occlusal adjustments and night guard’s replacement every two years.
For Class III Dental Services, benefits are paid on the preparation date, not the seat date.
Orthodontic Services: (the deductible is waived for Orthodontic services)
The Orthodontia Benefit is available only through age 18 (under the age of 19). Benefits are payable at 50%, limited to a lifetime maximum benefit payable of $1,200 per covered individual.
The Orthodontia Benefit provides coverage for non-surgical services to correct malocclusion (alignment of the teeth and/or jaws) that significantly interferes with their function. Necessary services related to an active course of Orthodontia treatment include diagnosis, initial installation of orthodontic appliances and adjustment of the appliances. Repair or replacement of Orthodontic appliances are not covered.
Benefits for Orthodontic services will cease as of the last day of the month:
- In which treatment ceases for any reason, or
- In which eligibility for coverage terminates, whether or not the course of treatment has been completed.