Caries medicament application – limited to 2 per tooth in any 1 Calendar Year. Space Maintainers - limited to non-Orthodontic Treatment for prematurely removed or missing teeth for a person less than 19 years old.
Covered Dental Services Teledentistry services are covered only when administered in conjunction with procedures and services which are covered under this plan. Covered Dental Services delivered through teledentistry are covered to the same extent We cover services rendered through in-person contact including the same cost- share, frequency limitations or any applicable benefit maximums or lack thereof. Class I Services – Diagnostic and Preventive Clinical oral evaluation – limited to 2 per person per Calendar Year. All oral cleaning services cross accumulate for frequency limit. Palliative treatment of dental pain, per visit - unlimited. Covered as a separate benefit and administrated at the In- Network coinsurance percentage only if no other services, other than exam and radiographic images, were performed during the visit. Full mouth or panoramic radiographic images – limited to 1 per person, including panoramic images, in any 36 consecutive months. Bitewing radiographic images – limited to 2 sets per person per Calendar Year. Extraoral posterior radiographic images – limited to 1 image in any Calendar Year. Prophylaxis (Cleaning) – limited to 2 per person per Calendar Year. Oral cleaning services include prophylaxis, periodontal maintenance, or scaling in the presence of gingival inflammation; all oral cleaning services cross accumulate for frequency limit. Periodontal maintenance procedures (following active therapy) – limited to 2 per person per Calendar Year. Oral cleaning services include prophylaxis, periodontal maintenance, and scaling in the presence of gingival inflammation; all oral cleaning services cross accumulate for frequency limit. Topical application of fluoride (excluding prophylaxis) – for a person less than 19 years old. Limited to 2 per person per Calendar Year. Sealant, per tooth, on an unrestored primary and permanent bicuspid or molar tooth only for a person less than 16 years old - limited to 1 treatment per tooth in any 36 consecutive months.
HC-DEN341
06-21 V2 M
Class II Services – Basic Restorations, Periodontics, Endodontics, Oral Surgery, Prosthodontic Maintenance Amalgam restorations – unlimited. Multiple restorations on one surface will be treated as a single restoration. The replacement of any amalgam restoration involving the same surface(s) on the same tooth, by the same Dentist or a different Dentist in the same office, within a 12 consecutive month period is considered as part of the charges for the initial placement. Resin-based composite restoration – unlimited. Multiple restorations on one surface will be treated as a single restoration. The replacement of any amalgam restoration involving the same surface(s) on the same tooth, by the same Dentist or a different Dentist in the same office, within a 12 consecutive month period is considered as part of the charges for the initial placement. Pin Retention - Covered only in conjunction with amalgam or resin-based composite restoration. Payable one time per restoration regardless of the number of pins used. Hydroxyapatite regeneration -limited to 1 service per tooth per consecutive 36 months. Root canal therapy - any radiographic images, test, laboratory exam or follow-up care is part of the allowance for root canal therapy and not a separate Covered Dental Service. Root canal therapy, retreatment - unlimited - covered only if more than 6 consecutive months have passed since the original endodontic therapy and only if necessity is confirmed by professional review. Gingivectomy or gingivoplasty - unlimited. Gingival flap procedure - including root planing - unlimited. Clinical crown lengthening - hard tissue - unlimited. Osseous surgery - flap entry and closure is part of the allowance for osseous surgery and not a separate Covered Dental Service - unlimited. Bone replacement graft - unlimited. Guided tissue regeneration - per site, per natural tooth – unlimited.
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