Class III Services - Major Restorations, Dentures and Bridgework Crowns - Initial placement of a crown is covered only when the tooth cannot be restored by an amalgam or resin-based composite restoration due to major decay or fracture. Replacement of a crown within 5 Calendar Years after the date it was originally installed is not covered. Stainless Steel Crowns, Resin Crowns - covered only when the tooth cannot be restored by an amalgam or resin-based composite restoration. Inlays - covered only when the tooth cannot be restored by an amalgam or resin-based composite restoration due to major decay or fracture. Onlays - covered only when the tooth cannot be restored by an amalgam or resin-based composite restoration due to major decay or fracture. Core buildup, including any pins. Post/post and core - covered only for endodontically treated teeth when there is insufficient tooth structure to retain the final restoration. Complete dentures - limited to 1 complete denture per arch within 5 Calendar Years. ` Partial Dentures - limited to 1 partial denture per arch within 5 Calendar Years. Overdentures - complete and partial - limited to 1 denture per arch per 5 Calendar Years. Fixed partial dentures/bridges, inlays and onlays (pontics and retainer crowns) - replacement is limited to 1 service per tooth per 5 Calendar Years if the previous fixed partial denture/bridges is not serviceable and cannot be repaired. Temporary clear appliance – limited to 1 service per arch per 12 consecutive months. Prosthesis Over Implant - A prosthetic device, supported by an implant or implant abutment is a Covered Dental Expense. Replacement of any type of prosthesis with a prosthesis supported by an implant or implant abutment is only payable if the existing prosthesis is at least 5 Calendar Years old, is not serviceable and cannot be repaired.
Benefits are payable under this plan only for active Orthodontic Treatment and for the orthodontic services listed below on the date the Orthodontic Treatment is started. No benefits are payable for retention in the absence of full active Orthodontic Treatment. Charges will be considered, subject to other plan conditions, as follows: • 25% of the total case fee will be considered as being incurred on the date the initial active appliance is placed; and • the remainder of the total case fee will be divided by the number of months for the total treatment plan and the resulting portion will be considered to be incurred on a monthly basis until the plan maximum is paid, treatment is completed or eligibility ends. Payments will be made quarterly. Covered Orthodontic Treatment includes: • Pre-Orthodontic Treatment examination to monitor growth and development; • Orthodontic work-up including: • intraoral complete series of radiographic images or panoramic radiographic images taken in conjunction with an Orthodontic Treatment plan (if needed); • cephalometric radiographic image (if needed); • radiographs (if needed); • diagnostic casts (i.e., study models) for orthodontic evaluation (if needed); • treatment plan (if needed); • Fixed or removable orthodontic appliances for limited tooth movement and/or limited tooth guidance; • Comprehensive Orthodontic Treatment adult and child; • Periodic Orthodontic Treatment visit; • Placement of device to facilitate eruption of impacted tooth; • Transseptal fiberotomy/supra crestal fiberotomy, by report; • Harmful habits treatment.
HC-DEN344
06-21
HC-DEN343
06-21 V2
Class IX Services – Implants Covered Dental Expenses include: the surgical placement of the dental implant body; the surgical implant index or surgical template guide used for implant surgery; implant abutment(s) and/or connecting bar(s); periodontal/peri-implant and/or maintenance services specifically related to a dental implant;
Class IV Services - Orthodontics The total amount payable for all expenses incurred for orthodontics during a Covered Person's lifetime will not be more than the orthodontia maximum shown in The Schedule.
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