Individual Incentive 10 Dental
Covered Services
Covered
Services are those services or supplies that are required to prevent, diagnose,
or treat diseases or conditions of the teeth and supporting tissues and are
Dentally Appropriate. These services must be performed by a Dentist or other
provider practicing within the scope of his or her license.
Subject to the limitations and conditions described in the policy, the following will be considered covered services under your policy:
Preventive Services
Cleanings, limited to 2 per benefit year, whether theyre
considered cleanings or periodontal maintenance (periodontal maintenance
covered under major services)
Oral exams allowed, two
per benefit year
Fluoride Treatment
allowed two applications
per benefit year for members age 17 and under
X-ray bitewings: allowed one set limited to
twice per benefit year, panoramic and full mouth series: limited to once every
three years
Sealants allowed for
permanent bicuspids and molars for members age 17 and under
Space Maintainers allowed for members age 11 and under
Restorative Services
Fillings, composite and
amalgam
Emergency treatment for
pain relief only
Oral surgery including surgical extractions,
removal of teeth, biopsies and incision and drainage
General anesthesia or intravenous sedation
allowed for members age 6 and under.
Direct pulp capping
Major Services
·
Crowns
or onlays and related services
·
Bridges
(fixed partial dentures)
·
Dentures
(full or partial) and related services
·
Endosteal Implants and related services; implants are limited to four per lifetime per member
·
Endodontics including root canal treatment, pulpotomy,
apicoectomy
·
Periodontal
maintenance, limited to 2 per benefit year in lieu of preventive
cleaning.
·
Scaling
and root planing allowed once every two years per
quadrant
·
Debridement
allowed once every three years
·
Gingivectomy and gingivoplasty allowed once
every three years per quadrant
Osseous and mucogingival surgery
allowed once every five years per quadrant
Replacement of prosthetics is limited to replacements made at
least seven years from the most recent placement; limited to once in a seven
year period.