Class A Services: Preventive and Diagnostic Dental Procedures
The limits on Class A Services are for routine services:
1. routine oral exams (This includes the scaling and polishing procedure to remove coronal plaque, calculus and stains. It does not include periodontal scaling and root planning. Limit of two exams every Calendar Year.),
2. two bitewing x-ray series per Calendar Year,
3. one full mouth x-ray or one panoramic x-ray every 36 months,
4. two fluoride treatments for covered dependent children under age 19 every 12 months, 5. space maintainers for covered dependent children under age 14 to replace primary teeth, 6. sealants for covered dependent
children under age 14,
7. emergency palliative treatment for pain,
8. other dental x-rays if required for diagnosis and treatment of specific conditions, or
9. consultations for preventive and basic dental procedures.
The limits on Class A Services are for routine services:
1. routine oral exams (This includes the scaling and polishing procedure to remove coronal plaque, calculus and stains. It does not include periodontal scaling and root planning. Limit of two exams per Calendar Year.),
2. two bitewing x-ray series per Calendar Year,
3. one full mouth x-ray or one panoramic x-ray every 36 months,
4. two fluoride treatments for covered dependent children under age 19 every 12 months, 5. space maintainers for covered dependent children under age 14 to replace primary teeth, 6. sealants for covered dependent
children under age 14,
7. emergency palliative treatment for pain,
8. other dental x-rays if required for diagnosis and treatment of specific conditions, or
9. consultations for preventive, basic, major and orthodontic dental procedures.
The limits on Class A Services are for the following routine services:
1. routine oral exams (This includes the scaling and polishing procedure to remove coronal plaque, calculus and stains. It does not include periodontal scaling and root planning. Limit of two exams per Calendar Year),
2. two bitewing x-ray series per Calendar Year,
3. one full mouth x-ray or one panoramic x-ray every 36 months,
4. two fluoride treatments for covered dependent children under age 19 every 12 months, 5. space maintainers for covered dependent children under age 14 to replace primary teeth, 6. sealants for covered dependent
children under age 14,
7. emergency palliative treatment for pain,
8. other dental x-rays if required for diagnosis and treatment of specific conditions, or
9. consultations for preventive, basic, major and orthodontic dental procedures.
Class B Services: Basic Dental Procedures
The limits on Class A Services are The limits on Class B Services are The limits on Class B Services are
for routine services:
1. oral surgery is limited to removal of teeth, preparation of the mouth for dentures and removal of tooth-generated cysts of less than 1/4 inch, 2. extractions This service
includes local anesthesia and routine post-operative care.
(Coverage excludes the extraction of wisdom teeth);
3. recementing bridges, crowns or inlays,
4. fillings, other than gold, 5. general anesthetics upon
demonstration of Medical Necessity
6. antibiotic drugs.
for routine services:
1. oral surgery is limited to removal of teeth, preparation of the mouth for dentures and removal of tooth-generated cysts of less than 1/4 inch, 2. extractions This service
includes local anesthesia and routine post-operative care.
3. recementing bridges, crowns or inlays,
4. fillings, other than gold, 5. general anesthetics upon
demonstration of Medical Necessity,
6. antibiotic drugs,
7. periodontics (gum treatments), 8. endodontics (root canals), 9. rebasing or relining of
removable dentures, 10. mouth guards for bruxism
(allowed once every 3 years).
for the following routine services:
1. oral surgery is limited to removal of teeth, preparation of the mouth for dentures and removal of tooth-generated cysts of less than 1/4 inch, 2. extractions. This service
includes local anesthesia and routine post-operative care.), 3. recementing bridges, crowns or
inlays,
4. fillings, other than gold, 5. general anesthetics upon
demonstration of Medical Necessity,
6. antibiotic drugs,
7. periodontics (gum treatments), 8. endodontics (root canals), 9. rebasing or relining of
removable dentures, 10. mouth guards for bruxism
(allowed once every 3 years).
Class C Services: Major Dental Procedures
There are no Class C Services provided under the Preventive Plan
The limits on Class C Services are for routine services:
1. gold restorations, including inlays, onlays and foil fillings (The cost of gold restorations in excess of the cost for amalgam, synthetic porcelain or plastic materials will be included only when the teeth must be restored with gold.),
2. installing precision attachments for removable dentures,
3. installing partial, full or removable dentures to replace one or more natural teeth. (This service also includes all
5. initial installation of fixed bridgework to replace one or more natural teeth which were extracted,
6. repair of crowns, bridgework
The limits on Class C Services are for the following routine services:
1. gold restorations, including inlays, onlays and foil fillings (The cost of gold restorations in excess of the cost for amalgam, synthetic porcelain or plastic materials will be included only when the teeth must be restored with gold.),
2. installing precision attachments for removable dentures,
3. installing partial, full or removable dentures to replace one or more natural teeth. (This service also includes all
5. initial installation of fixed bridgework to replace one or more natural teeth which were extracted,
6. repair of crowns, bridgework
and removable dentures, 7. Implants
8. replacing an existing removable partial or full denture or fixed bridgework; adding teeth to an existing removable partial denture; or adding teeth to existing bridgework to replace newly extracted natural teeth.;
however, this item will apply only if one of these tests is met:
a. The replacement or
addition of teeth is required because of one or more natural teeth being extracted.
b. The existing denture or bridgework was installed at least five years prior to its replacement and cannot must take place within 12 months from the date the temporary denture was installed.
and removable dentures, 7. Implants
8. replacing an existing removable partial or full denture or fixed bridgework; adding teeth to an existing removable partial denture; or adding teeth to existing bridgework to replace newly extracted natural teeth.;
however, this item will apply only if one of these tests is met:
a. The replacement or addition of teeth is required because of one or more natural teeth being extracted.
b. The existing denture or bridgework was installed at least five years prior to its replacement and cannot from the date the temporary denture was installed.
Class D Services: Orthodontic Treatment and Appliances There are no Class D Services
provided under the Preventive Plan
This is treatment to move teeth by means of appliances to correct a handicapping malocclusion of the mouth.
These services include: preliminary study (x-rays, diagnostic casts and treatment plan), active treatments and retention appliance.
Payments for comprehensive full-banded orthodontic treatments are made in installments. Benefits are paid at a percent of the total allowance after deductible is met, not to exceed the dental orthodontic maximum.
This is treatment to move teeth by means of appliances to correct a handicapping malocclusion of the mouth.
These services include preliminary study, including x-rays, diagnostic casts and treatment plan, active treatments and retention appliance.
Payments for comprehensive full-banded orthodontic treatments are made in installments. Benefits are paid at a percent of the total allowance after deductible is met not to exceed the dental orthodontic maximum.