Covered Expenses

The Plan’s coverage is based on Allowable Charges. “Allowable Charge” means the actual charge made by the provider of the care or supply, or if less, the amount determined by the claims administrator to be usual, customary, and reasonable (UCR) based on what other providers charge for the same service. Any reduction or discount credited to the participant by the provider will reduce the Allowable Charge, potentially causing an overpayment that the Plan may recover from you.

Preventive Services

The Plan covers the following preventive services at 100% of Allowable Charges:

  • Two exams per calendar year, including teeth cleaning and partial X-rays
  • Bite-wing X-rays
  • Full-mouth X-rays every 36 months
  • Space maintainers to keep teeth from moving into space left when permanent teeth are pulled
  • Tests to see if a tooth is still alive
  • Painting teeth with fluoride to help prevent cavities
  • Application of sealants to molar teeth of children under age 19, with repeat applications limited to intervals of at least five years
  • Emergency care

Basic Services

The Plan covers the following basic services at 80% of Allowable Charges:

  • Fillings (amalgam or tooth-colored)
  • Pulling of teeth (either simple extractions or surgical removal) and anesthesia
  • Care for problems with pulp inside a tooth
  • Removal of diseased portions of bone around the teeth
  • Care for acute gum infection or sores
  • Dental care for the gums, including replacement of infected gum parts
  • Cleaning below the gums
  • Surgery on the lining of the gums
  • Root canals
  • Repair of false teeth
  • Re-cementing crowns, inlays, and bridges
  • Preparing the gum ridges for false teeth
  • Covered dental care received in your home

Major Services

The Plan covers the following major services at 50% of Allowable Charges:

  • Gold and porcelain fillings
  • Crowns
  • Inlays
  • Onlays
  • Dentures (once every five years)
  • Bridges (once every five years)
  • Relining of dentures for better fit
  • Oral surgery
  • Veneers
  • Occlusal guards

If a temporary denture is provided before a permanent one, only the charge for the permanent denture is considered. Denture adjustments or relining during the first six months after installation are considered part of the initial charge for the denture.

Orthodontic Services

The Plan covers the following orthodontic services to treat a handicapping malocclusion (i.e., a dental problem that prevents normal chewing or eating) at 50% of Allowable Charges:

  • Installation of orthodontic appliances
  • Treating side effects of the condition
  • Diagnostic services, including X-rays and study models