Eligible Dental Services
CLASS 1 SERVICES: PREVENTATIVE AND DIAGNOSTIC DENTAL PROCEDURES
The limits on Class 1 Services are for routine services.
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If a dental need is present, the membership will consider sharing in services.
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Routine oral exams, including the cleaning and scaling of teeth limit of two exams eligible member, per membership year.
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One bitewing x-ray series every six months.
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One full mouth x-ray or panoramic x-ray every five years.
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One fluoride treatment for eligible dependent children under age 19 every 12 months.
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Space maintainers for eligible dependent children under age 19.
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Periodontal maintenance procedures following periodontal surgery.
CLASS 2 SERVICES: BASIC DENTAL PROCEDURES
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Amalgam or resin fillings
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General anesthetics upon demonstration of medical necessity
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Extractions
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Oral surgery
CLASS 3 SERVICES: MAJOR DENTAL PROCEDURES
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Inlays, onlays, crowns, laminates and gold foils. Limited to once in a ten-year period for the same tooth surface.
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Replacing inlays, onlays and crowns once every ten years
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Root canal treatment
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Periodontal surgery
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Repair or recement of crowns, inlays, onlays, dentures or bridges
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Repair or reline of dentures
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Those dental services needed to replace one or more natural teeth which were extracted while the member was covered for these benefits:
(a) Installation of fixed bridgework done for the first time;
(b) Installation for the first time of a partial or full removable denture;
(c) Replacing an existing removable denture or fixed bridgework if:
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It is needed because of the loss on one or more natural teeth after the existing denture or bridgework was installed; or
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It is needed because the existing denture or bridgework can no longer be used and was installed at least ten years prior to its replacement.
(d) Replacing an existing immediate temporary full denture by a new permanent full denture when:
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The existing denture cannot be made permanent; and
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The permanent denture is installed within 12 months after the existing denture was installed.
(e) Adding teeth to an existing partial removable denture or to bridgework when needed to replace one or more natural teeth extracted after the existing denture or bridgework was installed.
(f) Denture adjustment limited to once every 12 months.