Individual & Family Plans Dental Coverage
Pediatric check-up care for children
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.
Orthodontia for children
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.
Major dental care for children
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.)