Coverage is per person per calendar year (January –December)
Enhanced Option 1: 50% of the Dental Benefit List fees for basic treatments up to a maximum of $2,500
Enhanced Option 2: 80% of the Dental Benefit List fees for basic treatments up to a maximum of $1,000
Core: 50% of the Dental Benefit List fees for basic treatments up to $2,000
Following is a list of some common basic preventative and restorative procedures and coverage limitations:
Dental Exam (recall and specific exams): One recall or specific exam is eligible for coverage every six months from the date of last service for people under 19 and every 12 months for those 19 and older. Additional exams may be covered for people with certain health conditions—please see the Oral Health Exception Process section for details.
Complete Dental Exams: Complete dental exams are eligible for coverage once every 30 months from the date of last service.
Emergency Exams: Emergency exams are covered anytime, but only in conjunction with other emergency services, like extractions, or a written explanation on the claim form from your dental provider regarding the nature of the emergency. For example, it’s not considered an emergency if an x-ray is performed and no resulting emergency procedures are performed.
Fillings: Fillings are limited to five surfaces per tooth every 24 months from the date of the last service.
Fluoride Applications: Fluoride applications are eligible for coverage once every six months from date of last service for people under 19. Additional fluoride applications may be covered for people with certain health conditions—please see the Oral Health Exception Process section for details.
Polishing: One half unit of polishing is eligible for coverage once every six months from the date of last service for people under 19.
X-Rays (Bitewing): Bitewing X-rays are eligible for coverage once every six months from the date of last service for people under 19 and once every 12 months for those 19 and older.
Panoramic and Full-Mouth X-Rays: Panoramic and full-mouth X-rays are eligible for coverage once every five years from the date of last service.
Scaling and Root Planing: Scaling and root planing are limited to 12 units of time (one unit of time is equal to 15 minutes) per person, based on a rolling one-year period from the date of last service.
General Anesthetic: General anesthetic is eligible for coverage only in conjunction with eligible surgical procedures (e.g. surgical extractions) and excludes anesthetic facility (such as a recovery room), equipment and supply fees.
Extractions: There are no specific limitations for tooth extractions.
Root Canals (Endodontics): Root canals for the same tooth are only covered once every 24 months. Treatment of previously-completed root canals require a dental predetermination (treatment plan) to be completed prior to treatment.
Specialist Referral Exam: Specialist referral exams are limited to once every 12 months per dental specialty from the date of last service. Referral to a specialist is made by your family dentist. Orthodontic referrals are covered under orthodontic services.
