Coverage is limited to covered persons through the end of the month in which
the person turns 19
Routine vision exams (including refraction)
Performed by an ophthalmologist or optometrist 0% per visit
Visit limit per Calendar Year 1 visit
*Important note:
Refer to the Vision care section in the Certificate for the explanation of these vision care supplies. As to coverage for Prescription lenses in a Contract Year, this benefit will cover either Prescription lenses for eyeglass frames or Prescription contact lenses, but not both. Coverage does not include the office visit for the fittingof Prescription contact lenses.
*See How to read the Schedule of Benefits at the beginning of this Schedule of Benefits
Pediatric dental
Coverage is limited to covered persons through the end of the month in which
the person turns 19
Type A services 0%
Type B services 30%
Type C services 50%
Orthodontic services 50%
Dental emergency limit: $75
The dental emergency limit is the most the plan will pay for health care services incurred by a Member
for any one dental emergency.
Dental benefits are subject to the medical plan’s Deductibles and Maximum Out-of-Pocket Limits as explained on the Schedule of Benefits.
Type A Services: Diagnostic and Preventive Care
Visits and images
(D0120) Office visit during regular office hours, for oral examination (limited to: 2 visits every 12 months)
(D0160) Routine comprehensive or recall examination (limited to: 2 visits every 12 months) (D0150, D0180) Comprehensive periodontal evaluation (limited to: 2 visits every 12 months) (D0140) Problem-focused examination (limited to: 2 visits every 12 months)
(D1110, D1120) Prophylaxis (cleaning) (limited to: 2 treatments per year) (D1208) Topical application of fluoride (limited to: 2 courses every 12 months) (D1206) Topical fluoride varnish (limited to: 2 courses every 12 months)
(D1351) Sealants, per tooth (limited to: one application every 3 years for permanent molars) (D1352) Preventive resin restoration in a moderate to high caries risk patient-permanent tooth (limited to: one application every 3 years for permanent molars)
(D0270-D0274) Bitewing images (limited to: 2 sets per 12 months)
(D0210) Complete image series, including bitewings (limited to: 1 set every 3 years) (D0330) Panoramic images (limited to: 1 set every 3 years)
(D0340) Cephalometric image
(D0350) Oral facial photographic images (D0470) Diagnostic models
(D0277) Vertical bitewing images (limited to: 2 sets per year) (D0220, D0230) Periapical images
(D0240) Intra-oral, occlusal view, maxillary or mandibular (D9110) Emergency palliative treatment per visit
Note: Diagnostic procedures of: D0330, D0340, D0350 and D0470 are covered as Type A benefit for a non-vested orthodontia patient.
Space maintainers
(Includes all adjustments within 6 months after installation) (D1510, D1515) Fixed (unilateral or bilateral)
(D1520, D1525) Removable (unilateral or bilateral) (D1550) Re-cementation of space maintainer (D1555) Removal of space maintainer
*See How to read the Schedule of Benefits at the beginning of this Schedule of Benefits
Type B Services: Basic Restorative Care
Visits and images
(D9440) Professional visit after hours (payment will be made on the basis of services rendered the charge for the after-hours visit, whichever is greater)
(D9310) Consultation (by other than the treating provider)
(D9930) Treatment of complications (post surgical) unusual circumstances, by report
Images and pathology
(D0250-D0260) Upper or lower jaw, extra-oral (D9610) Therapeutic drug injection, by report
Oral surgery
(D7111) Extraction, coronal remnants-deciduous tooth
(D7140) Extraction, erupted tooth or exposed root (elevation and/or forceps removal)
(D7210) Surgical removal of erupted tooth requiring removal of bone and/or resectioning of tooth (D7251) Coronal remnants
(D7250) Surgical removal of erupted tooth/root tip
Surgical removal of impacted teeth
(D7220) Removal of impacted tooth (soft tissue) (D7230) Removal of impacted tooth (partially bony) (D7240) Removal of impacted tooth (completely bony)
(D7241) Removal of impacted tooth (completely bony with unusual surgical complications) (D7510) Incision and drainage of abscess
(D7450, D7451) Removal of odontogenic cyst or tumor (D7280) Other surgical procedures
(D7310) Alveoplasty, in conjunction with extractions - per quadrant
(D7311) Alveoplasty, in conjunction with extractions, 1 to 3 teeth or tooth spaces - per quadrant (D7320) Alveoplasty, not in conjunction with extraction - per quadrant
(D7321) Alveoplasty, not in conjunction with extractions, 1 to 3 teeth or tooth spaces - per quadrant (D7980) Sialolithotomy: removal of salivary calculus
(D7983) Closure of salivary fistula (D7970) Excision of hyperplastic tissue (D7471) Removal of exostosis
(D7270) Tooth re-implantation
(D7272) Transplantation of tooth or tooth bud (D7260) Closure of oral fistula of maxillary sinus (D7550) Sequestrectomy
(D7283) Crown exposure to aid eruption
(D7530) Removal of foreign body from soft tissue (D7960) Frenectomy
(D7910) Suture of soft tissue injury (D7971) Excision of pericornal gingiva
Periodontics
(D9951, D9952) Occlusal adjustment (other than with an appliance or by restoration)
(D4341) Periodontal scaling and root planing, per quadrant (limited to 4 separate quadrants every 2 years)
*See How to read the Schedule of Benefits at the beginning of this Schedule of Benefits (D4342) Root planing and scaling – 1 to 3 teeth per quadrant (limited to once per site every 2 years) (D4910) Periodontal maintenance procedures following active therapy (limited to: 4 in 12 months) (combined with prophylaxis after completion of active periodontal therapy)
(D4381) Localized delivery of antimicrobial agents
Endodontics (D3110-D3120) Pulp capping (D3220-D3222) Pulpotomy (D3230-D3240) Pulpal therapy (D3355-D3357) Pulpal regeneration Restorative dentistry
Excludes inlays, crowns (other than prefabricated stainless steel or resin) and bridges. Multiple restorations in 1 surface will be considered as a single restoration.
(D2140, D2150, D2160, D2161) Amalgam restorations - one, two three, four or more surfaces, primary or permanent teeth
(D2330, D2331, D2332, D2335) Resin-based composite – one, two three, four or more surfaces, anterior
(D2390) Resin-based composite crown, anterior
(D2391, D2392, D2393, D2394) Resin-based composite - one, two, three, four or more surfaces, posterior
Pins
(D2951) Pin retention—per tooth, in addition to amalgam or resin restoration
Crowns (when tooth cannot be restored with a filling material)
(D2930-D2931) Prefabricated stainless steel
(D2932) Prefabricated resin crown (excluding temporary crowns) (D2940) Protective resin Re-cementation (D2910) Inlay (D2920) Crown (D6930) Bridge Prosthodontics Dentures and partials
(D5730, D5731) Office reline, complete denture - maxillary or mandibular (D5740, D5741) Office reline, partial denture - maxillary or mandibular
(D5750, D5751) Reline, complete denture - maxillary or mandibular - laboratory (D5760, D5761) Reline, partial denture - maxillary or mandibular - laboratory (D5850, D5851) Special tissue conditioning, per denture - maxillary or mandibular (D5710, D5711) Rebase complete denture - maxillary or mandibular
(D5720, D5721) Rebase partial denture - maxillary or mandibular
(D5410, D5411) Adjustment to complete denture (more than 6 months after installation) - maxillary or mandibular
*See How to read the Schedule of Benefits at the beginning of this Schedule of Benefits (D5421, D5422) Adjustment to partial denture (more than 6 months after installation) - maxillary or
mandibular
Repairs: Dentures and partial dentures
D6980) Fixed partial denture repair, by report (D5510) Repair broken complete denture base
(D5520) Replace missing or broken teeth – complete denture (each tooth) (D5610) Repair resin denture base
(D5620) Repair cast framework
(D5630) Broken denture clasp, no teeth involved (D5640) Replacing missing or broken teeth, each tooth Adding teeth to existing partial denture
(D5650) Each tooth (D5660) Each clasp
General anesthesia and intravenous sedation
Only when medically necessary and only when provided in conjunction with a covered dental surgical procedure
(D9220) Deep sedation/general anesthesia – first 30 minutes
(D9221) Deep sedation/general anesthesia – each additional 15 minutes (D9241) Intravenous conscious sedation – first 30 minutes
(D9242) Intravenous conscious sedation – each additional 15 minutes
Type C Services: Major Restorative Care
Periodontics
(D4261) Osseous surgery, including flap and closure, 1 to 3 teeth per quadrant (limited to 1 per site every 3 years)
(D4260) Osseous surgery, including flap and closure, (limited to 1 per quadrant every 3 years) (D4270) Pedicle soft tissue graft procedure
(D4277, D4278) Free soft tissue graft procedures
(D4273) Subepithelial connective tissue graft procedure (including donor site surgery) (D4210) Gingivectomy, per quadrant (limited to 1 per quadrant every 3 years)
(D4211) Gingivectomy, 1 to 3 teeth per quadrant
(D4240) Gingival flap procedure - per quadrant (limited to 1 per quadrant every 3 years) (D4241) Gingival flap procedure – 1 to 3 teeth per quadrant (limited to 1 per site every 3 years) (D4249) Clinical crown lengthening
(D4355) Full mouth debridement (limited to 1 treatment per lifetime)
Endodontics
(D3351, D3352, D3353) Apexification/recalcification
(D3410, D3421, D3425, D3426) Apicoectomy/periradicular surgery – anterior/bicuspid/molar/each additional root
(D3354) Pulpal regeneration
Root canal therapy including medically necessary images: (D3310) Anterior
(D3320) Bicuspid (D3330) Molar
*See How to read the Schedule of Benefits at the beginning of this Schedule of Benefits (D3346) Anterior
(D3347) Bicuspid (D3348) Molar
(D3450) Root amputation
(D3920) Hemisection (including any root removal)
Restorative
Inlays, onlays, labial veneers and crowns when provided as treatment for decay or acute traumatic injury and only when teeth cannot be restored with a filling material or when the tooth is an abutment to a fixed bridge (limited to: 1 per tooth every 5 years)
Inlays/Onlays(limited to: 1 tooth every 5 years)
(D2510, D2520, D2530) Inlay – metallic, one, two, three surfaces
(D2542, D2543, D2544) Onlay – metallic, one, two, three and four or more surfaces (D2610, D2620, D2630) Inlay – porcelain/ceramic, one, two, three or more surfaces (D2642, D2643, D2644) Onlay– porcelain/ceramic, two, three and four or more surfaces (D2650, D2651, D2652) Inlay – resin based composite, one, two, three or more surfaces (D2662, D2663, D2664) Onlay – resin based composite, two, three and four or more surfaces
Crowns (limited to: 1 tooth every 5 years)
(D2710) Resin-based composite (D2712) 3/4 resin based composite (D2720) Resin with high noble metal (D2721) Resin with base metal (D2722) Resin with noble metal (D2740) Porcelain/ceramic substrate (D2750) Porcelain fused to noble metal
(D2751) Porcelain fused to predominately base metal (limited to: 1 tooth every 5 years) (D2752) Porcelain fused to noble metal
(D2790) Full cast high noble metal (D2791) Base metal (full cast) (D2792) Noble metal (full cast) (D2780) 3/4 cast high noble metal (D2781) 3/4 cast base metal (D2782) 3/4 cast noble metal (D2783) 3/4 porcelain/ceramic (D2794) Titanium
(D2950) Core build-up, including any pins
(D2952,D2953) Post and core in addition to crown, indirectly fabricated (D2954) Prefabricated post and core, in addition to crown
(D2980) Crown repair
Prosthodontics
Installation of dentures and bridges is covered only if needed to replace teeth which were not abutments to a denture or bridge/partial denture less than 5 years old.
Replacement of existing bridges/partial denture or dentures (limited to: 1 every 5 years)
*See How to read the Schedule of Benefits at the beginning of this Schedule of Benefits
Pontics(limited to: 1 tooth every 5 years)
(D6210) Cast high noble metal (D6211) Cast base metal (D6212) Cast noble metal (D6214) Titanium
(D6240) Porcelain fused to high noble metal (D6241) Porcelain fused to base metal (D6242) Porcelain fused to noble metal (D6245) Porcelain/ceramic
(D6250) Resin with high noble (D6251) Resin with base metal (D6252) Resin with noble metal
(D6545) Retainer cast metal for resin bonded fixed prosthesis (limited to: 1 tooth every 5 years)
(D6548) Retainer porcelain/ceramic for resin bonded fixed prosthesis (limited to: 1 tooth every 5 years)
Fixed partial denture retainers-Crowns(limited to: 1 tooth every 5 years)
(D6740) Porcelain/ceramic
(D6750) Porcelain fused to high noble metal (D6751) Porcelain fused to base metal (D6752) Porcelain fused to noble metal (D6780) 3/4 cast high noble metal (D6781) 3/4 cast base metal (D6782) 3/4 cast noble metal (D6783) 3/4 porcelain/ceramic (D6790) Full cast high noble metal (D6791) Full cast base metal (D6792) Full cast noble metal (D6794 Titanium
(D5281) Removable partial denture (unilateral) (limited to: 1 every 5 years)
One piece casting, chrome cobalt alloy clasp attachment (all types) per unit, including pontics
(limited to: 1 every 5 years)
Dentures and Partials (limited to: 1 every 5 years) Fees for dentures and partial dentures include relines, rebases and adjustments within 6 months after installation. Fees for relines and rebases include adjustments within 6 months after installation. Specialized techniques and characterizations are not eligible)
(D5110) Complete upper denture (D5120) Complete lower denture (D5130) Immediate upper denture (D5140) Immediate lower denture
(D5211, D5212) Partial upper or lower, resin base (including any conventional clasps, rests and teeth)
(D5213, D5214) Partial upper or lower, cast metal base with resin saddles (including any conventional clasps, rests and teeth)
*See How to read the Schedule of Benefits at the beginning of this Schedule of Benefits
Implants and implant services(Only if determined as a dental necessity and limited to 1 every 5 years)
(D6010) Endosteal Implant
(D6012) Surgical placement of interim implant body (D6040) Eposteal implant
(D6050) Transosteal implant, including hardware (D6053) Implant supported complete denture (D6054) Implant supported partial denture
(D6055) Connecting bar – implant or abutment supported (D6056) Prefabricated abutment
(D6058) Abutment supported porcelain ceramic crown
(D6059) Abutment supported porcelain fused to high noble metal
(D6060) Abutment supported porcelain fused to predominately base metal crown (D6061) Abutment supported porcelain fused to noble metal crown
(D6062) Abutment supported cast high noble metal crown
(D6063) Abutment supported cast predominately base metal crown (D6064) Abutment supported cast noble metal crown
(D6065) Implant supported porcelain/ceramic crown
(D6066) Implant supported porcelain fused to high noble metal (D6067) Implant supported metal crown
(D6068) Abutment supported retainer for porcelain/ceramic fixed partial denture
(D6069) Abutment supported retainer for porcelain fused to high noble metal fixed partial denture
(D6070) Abutment supported retainer for porcelain fused to predominately base metal fixed partial denture
(D6071) Abutment supported retainer for porcelain fused to noble metal fixed partial denture (D6072) Abutment supported retainer for cast high noble metal fixed partial denture
(D6073) Abutment supported retainer for predominately base metal fixed partial denture (D6074) Abutment supported retainer for cast noble metal fixed partial denture
(D6075) Implant supported retainer for ceramic fixed partial denture
(D6076) Implant supported retainer for porcelain fused to high noble metal fixed partial denture
(D6077) Implant supported retainer for cast metal fixed partial denture
(D6078, D6079) Implant supported complete denture, partial denture (limited to 1 every 5 years)
(D6080) Implant maintenance procedures (limited to 1 every 5 years) (D6090) Repair implant prosthesis
(D6091) Replacement of semi-precious or precision attachment (D6094) Abutment supported crown titanium
(D6095) Repair implant abutment (D6100) Implant removal, by report
(D6110, D6111) Implant/abutment supported removable denture, maxillary or mandibular (D6112, D6113) Implant/abutment supported removable denture for partially edentulous arch, maxillary or mandibular
(D6114, D6115) Implant/abutment supported fixed denture for completely edentulous arch – maxillary or mandibular
*See How to read the Schedule of Benefits at the beginning of this Schedule of Benefits (D6116, D6117) Implant/abutment supported fixed denture for partially edentulous arch – maxillary or mandibular
(D6100) Implant removal, by report (D6190) Implant index
(D6194) Abutment supported retainer crown for fixed partial denture titanium
Other services
(D6940) Stress breakers
(D6985) Interim partial denture (stayplate), anterior only (D9940) Occlusal guard, by report (limited to 1 in 12 months) (D8210) Removable appliance therapy
(D8220) Fixed appliance therapy
Orthodontic services
Medically necessary comprehensive treatment
(D8010) Limited orthodontic treatment of the primary dentition (D8020) Limited orthodontic treatment of the transitional dentition (D8030) Limited orthodontic treatment of the adolescent dentition (D8040) Limited orthodontic treatment of the adult dentition (D8050) Interceptive orthodontic treatment of the primary dentition (D8060) Interceptive orthodontic treatment of the transitional dentition (D8070) Comprehensive orthodontic treatment of the transitional dentition (D8080) Comprehensive orthodontic treatment of the adolescent dentition (D8090) Comprehensive treatment of adult dentition
(D8660) Pre-orthodontic treatment examination to monitor growth and development (D8670) Periodic orthodontic treatment visit (as part of contract)
(D8680) Orthodontic retention (removal of appliances, construction and placement of retainer(s) (D8691) Repair of orthodontic appliance
(D8693) Rebonding or recementing; and/or repair, as required of fixed retainers (D8694) Repair of fixed retainers
Orthodontic treatment (includes removal of appliance, construction and placement of retainer) Replacement of retainer (limited to: 1 per lifetime)
Note: Benefits for codes D0330, D0340, D0350, and D0470 will be considered orthodontia when performed as part of orthodontic treatment.