Individual & Family Plans Dental Coverage

The following pediatric dental services are covered for members under age 19:

• Periodic oral evaluation – one every six months
• Limited oral evaluation – one every six months
• Oral evaluation – one every six months
• Periodontal evaluation – one every six months
• Dental x-rays – complete series (including bitewings) – one every 60 months
• Dental x-rays – periapical and occlusal films
• Bitewings – one set every six months
• Vertical bitewings – seven to eight films – one set every six months
• Panoramic film – one film every 60 months
• Cephalometric radiographic image
• Oral / Facial photographic images
• Interpretation of diagnostic image
• Diagnostic models
• Prophylaxis – one every six months
• Topical application of fluoride (excluding prophylaxis) – two every 12 months
• Sealant – per tooth – unrestored permanent molars – one sealant per tooth every 36 months
• Space maintainers – fixed and removable – unilateral and bilateral
• Re-cementing space maintainer

For pediatric check-up dental services provided by non-network providers, you pay 50 percent after the non-network deductible has been met.

The following pediatric dental services are covered for members under age 19:

Orthodontics to help restore oral structures to health and function and to treat serious medical conditions such as:

• cleft palate and cleft lip
• maxillary/mandibular micrognathia (underdeveloped upper or lower jaw)
• extreme mandibular prognathism
• severe asymmetry (craniofacial anomalies)
• ankylosis of the temporomandibular joint
• and other major skeletal conditions

The following orthodontia dental services are not covered:

• Services from non network providers.
• Cosmetic services, such as appliances and braces to improve the appearance of the teeth.
• Orthodontia services for members 19 and older.

The following pediatric dental services are covered for members under age 19.

Restorative services:

• Amalgam and resin-based composite filings
• Root canal
• Extractions
• Periodontal scaling and root planing once every 24 months
• Full mouth debridement once per lifetime
• Crowns – limited to one per tooth, per 60 months
• Some inlays and onlays – one per tooth, per 60 months
• Complete and partial dentures, bridges – limited to one in a 60 month period, adjustments, repairs, relines, and rebases, every 36 months
• Some complex oral surgery
• Implants – one every 60 months

The following dental services are not covered:

• Services from non network providers.
• Dental services for members 19 and older.
• Temporary services (e.g. provisional crowns, interim dentures, et al.)