Covered Dental Care Services Sample Clauses

Covered Dental Care Services. This plan covers dentally necessary services and medically necessary orthodontic services (braces) up to the benefit limit provided below. See the Summary of Medical Benefits for the amount you pay. • Oral Evaluations - two (2) examinations per plan year; examinations include the initial or periodic examination, or an emergency oral evaluation, when performed by a general dentist, including diagnosis and charting. • X-rays - four (4) single x-rays per plan year; two (2) sets of bitewings per plan year; and one full mouth series (FMX) or panorex per 60-month period. • Cleanings (Prophylaxis) - two (2) cleanings per plan year. • Fluoride Treatments - two (2) fluoride treatments per plan year. • Sealants - permanent molars only; one sealant per tooth in a 36-month period. • Space Maintainers. • Palliative Treatment - two (2) visits for minor treatment to relieve sudden, intense pain per plan year. • Fillings. • Simple Extractions - the removal of an erupted tooth (non-surgical). • Denture Repairs and Relines/Rebasing - full or partial denture repairs, relines, and rebasing are limited to once in a 36-month period. • Crowns & Onlays - replacement is limited to once in a 60-month period; predetermination is recommended. • Therapeutic Pulpotomies. • Root Canal Therapy. • Non-Surgical Periodontal Services. • Surgical Periodontal Services - predetermination is recommended. • Periodontal Maintenance - two (2) services in a plan year. • Fixed Bridges and Dentures - replacements are limited to one (per tooth/unit) in a 60-month period; crowns over implants are considered a prosthodontic service; predetermination is recommended. • Dental Implants - replacements are limited to one (1) in a 60-month period; predetermination is recommended. • Oral Surgery Services. • Occlusal (Night) guards - one (1) occlusal (night) guard in a 12-month period; occlusal (night) guard adjustments are covered once in a twenty-four (24) month period. • Orthodontic Services (Braces) - only medically necessary braces are covered; predetermination is recommended. • General Anesthesia or IV Sedation in a Dental Office - covered as a separate benefit when performed in conjunction with covered oral surgery procedure(s) in accordance with our dental policies and related treatment guidelines. • Biopsies - limited to the biopsy and examination of oral tissue, soft or hard. Multi-Stage Procedures This plan covers multi-stage procedures that have a start date before the effective date of this plan if:...
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Covered Dental Care Services. We cover the following services when rendered by a dentist. All covered dental services are subject to the provisions below. See the Summary of Benefits to determine level of coverage and the amount you pay. If a service or category of service is not specifically listed as covered, it is not covered under this agreement. Only services that we have reviewed and determined are eligible for coverage under this agreement are covered. All other services are not covered. See The Summary of Benefits to determine if a service or category of service is covered. This agreement covers multi-stage procedures which have a start date before the effective date of this agreement if:  the multi-stage procedures have a completion date after the effective date of this agreement; and  the multi-stage procedures are covered dental services under this agreement. Subject to any plan year or other maximums, we will pay up to our allowance less any benefits paid or payable under any previous plan for multi-stage procedures. Pediatric Dental Care Services In accordance with PPACA, this agreement provides coverage for the dentally necessary services listed in the Summary of Benefits for an enrolled child under the age of nineteen (19), when rendered by a network dentist or non-network dentist. The coverage for dental care services rendered to an enrolled child will end for the child on the first day of the month following their 19th birthday, unless otherwise specified in the Summary of Benefits. If a covered dental care service is rendered more than our contractually specified treatment time or age limitations, which are based on our dental policies and related guidelines, it is not covered.
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Related to Covered Dental Care Services

  • Dental Care a. Dental Care for Members over age 19 is limited to the following:

  • Dental Care Plan The Welfare Plan will include a Dental Care Plan which will reimburse members for expenses incurred in respect of the coverages summarized in Appendix "1". The Plan will not duplicate benefits provided now or which may be provided in the future by any government program.

  • Vision Care Services For purposes of coordination of benefits, vision care services covered under other plans are not considered an allowable expense, as defined in the Coordination of Benefits and Subrogation in Section 7.

  • Dental Care Benefits (a) The Employer shall provide such regular, full-time seniority employee (and his eligible dependents*) the 100/75/50 Co-Pay Dental Plan in effect as of the date of this Agreement, subject to such terms, conditions, exclusions, limitations, deductibles, co-payments and other provisions of the plan. The Employer shall pay 95% of the illustrated premium cost of such benefits and the employee shall pay the balance. Coverage shall commence on the day following the employee’s ninetieth (90th) day of continuous employment.

  • COVERED HEALTHCARE SERVICES This section describes covered healthcare services. This plan covers services only if they meet all of the following requirements: • Listed as a covered healthcare service in this section. The fact that a provider has prescribed or recommended a service, or that it is the only available treatment for an illness or injury does not mean it is a covered healthcare service under this plan. • Medically necessary, consistent with our medical policies and related guidelines at the time the services are provided. • Not listed in Exclusions Section. • Received while a member is enrolled in the plan. • Consistent with applicable state or federal law. We review medical necessity in accordance with our medical policies and related guidelines. Our medical policies can be found on our website. Our medical policies are written to help administer benefits for the purpose of claims payment. They are made available to you for informational purposes and are subject to change. Medical policies are not meant to be used as a guide for your medical treatment. Your medical treatment remains a decision made by you with your physician. If you have questions about our medical policies, please call Customer Service. When a new service or drug becomes available, when possible, we will review it within six (6) months of one of the events described below to determine whether the new service or drug will be covered: • the assignment of an American Medical Association (AMA) Current Procedural Terminology (CPT) code in the annual CPT publication; • final Food and Drug Administration (FDA) approval; • the assignment of processing codes other than CPT codes or approval by governing or regulatory bodies other than the FDA; • submission to us of a claim meeting the criteria above; and • generally, the first date an FDA approved prescription drug is available in pharmacies (for prescription drug coverage only). During the review period, new services and drugs are not covered. For all covered healthcare services, please see the Summary of Medical Benefits and the Summary of Pharmacy Benefits to determine the amount that you pay and any benefit limits.

  • Leave for Medical and Dental Care (a) Where it is not possible to schedule medical and/or dental appointments outside regularly scheduled working hours, reasonable time off for medical and dental appointments for employees shall be permitted, if the Employer is notified at the time the appointment is made. Where any such absence exceeds two (2) hours, the full-time absence shall be charged to the entitlement described in Article 20.13.

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