Basic and Restorative Services. 7.7.2.1 Emergency Services (during office hours). 7.7.2.2 Pulp treatment.
Basic and Restorative Services. Fillings (restorations) – covered for primary or permanent teeth. Two types are covered: • Composite restorations are covered for anterior teeth only. Molar or Bicuspid teeth restorations will be alternative services and paid up to the maximum allowed for an Amalgam filling. Any remaining expenses incurred is the Member’s responsibility. One surface having multiple restorations is counted as one restoration. • Amalgam restorations are a mixture of metals formed to fill cavities that resulted from tooth decay; also known as “silver fillings”. One surface having multiple restorations is counted as one restoration. Pin Retention – Limit 1 time per 5 years. Covered as an addition to a restoration that is not combined with core build-up. Endodontic Therapy and Services – Covered on primary or permanent teeth. Limit once per tooth/root per lifetime. • Root Canal therapy and retreatment: includes treatment and fillings. Tests, labs, x-rays, intraoperative, tests, or other follow-up care is considered fundamental to the therapy. • Periradicular surgical procedures: refers to surgery to the external root surface and includes root amputation, tooth reimplementation, apicoectomy, and/or surgical isolation. • Partial pulpotomy for apexogenesis • Vital pulpotomy • Pulp debridement, pulp therapy • Apexification/recalcification
