Eligible Expenses
The Plan’s coverage is based on Allowable Charges. For purposes of the dental benefits provided under the Plan, “Allowable Charge” means the actual charge made by the provider of the care or supply, or if less, the amount determined by the Plan to be usual, customary, and reasonable (UCR) based on what other providers charge for the same service. Any reduction or discount credited to the member 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, up to $1,500 per year, combined with basic and major services:
- 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, 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, up to $1,500 per year, combined with preventive and major services:
- 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, up to $1,500 per year, combined with preventive and basic services:
- 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, up to $1,500 per lifetime:
- Installation of orthodontic appliances
- Treating side effects of the condition
- Diagnostic services, including X-rays and study models
