Dental Services - Accidental Injury (Emergency. Emergency room - When services are due to accidental injury to sound natural teeth. 0% - After deductible The level of coverage is the same as network provider. In a physician’s/dentist’s office - When services are due to accidental injury to sound natural teeth. 0% - After deductible 40% - After deductible Services connected to dental care when performed in an outpatient facility * 0% - After deductible 40% - After deductible Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Dental Care (Pediatric) - for members under age 19 See Dental Services in Section 3 for benefit limits and details. These services only apply to an enrolled member under the age of 19. Oral evaluations 0% - After deductible 0% - After deductible X-rays 0% - After deductible 0% - After deductible Cleanings (prophylaxis) 0% - After deductible 0% - After deductible Fluoride treatments 0% - After deductible 0% - After deductible Sealants 0% - After deductible 0% - After deductible Space Maintainers 0% - After deductible 0% - After deductible Palliative treatment 50% - After deductible 50% - After deductible Fillings 50% - After deductible 50% - After deductible Simple extractions 50% - After deductible 50% - After deductible Denture repairs and relines/rebasing 50% - After deductible 50% - After deductible Crowns & onlays 50% - After deductible 50% - After deductible Therapeutic Pulpotomies 50% - After deductible 50% - After deductible Root canal therapy 50% - After deductible 50% - After deductible Non-surgical periodontal services 50% - After deductible 50% - After deductible Surgical periodontal services 50% - After deductible 50% - After deductible Periodontal maintenance 50% - After deductible 50% - After deductible Fixed bridges and dentures 50% - After deductible 50% - After deductible Implants 50% - After deductible 50% - After deductible Oral surgery services 50% - After deductible 50% - After deductible General anesthesia or IV sedation - dental office 50% - After deductible 50% - After deductible Biopsies 50% - After deductible 50% - After deductible Occlusal (night) guards 50% - After deductible 50% - After deductible Orthodontic services (braces) - when medically necessary. 50% - After deductible 50% - After deductible Inpatient/outpatient/in your home 0% - Afte...
Dental Services - Accidental Injury (Emergency. Emergency room - When services are due to accidental injury to sound natural teeth. 0% - After deductible The level of coverage is the same as network provider. In a physician’s/dentist’s office - When services are due to accidental injury to sound natural teeth. 0% - After deductible Not Covered Services connected to dental care when performed in an outpatient facility * 0% - After deductible Not Covered Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Inpatient/outpatient/in your home 0% - After deductible Not Covered Durable Medical Equipment (DME), Medical Supplies, Diabetic Supplies, Prosthetic Devices, and Enteral Formula or Food, Hair Prosthetics Outpatient durable medical equipment* - Must be provided by a licensed medical supply provider. 20% - After deductible Not Covered Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 20% - After deductible Not Covered Outpatient diabetic supplies/equipment purchased at licensed medical supply provider (other than a pharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacy. 20% - After deductible Not Covered Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 20% - After deductible Not Covered Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 20% - After deductible Not Covered Enteral formula or food taken orally * 20% - After deductible The level of coverage is the same as network provider. Hair prosthesis (wigs) - The benefit limit is $350 per hair prosthesis (wig) when worn for hair loss suffered as a result of cancer treatment. 20% - After deductible The level of coverage is the same as network provider.
Dental Services - Accidental Injury (Emergency. Emergency room - When services are due to accidental injury to sound natural teeth. $100 The level of coverage is the same as network provider. In a physician’s/dentist’s office - When services are due to accidental injury to sound natural teeth. $30 Not Covered (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Services connected to dental care when performed in an outpatient facility * 0% - After deductible Not Covered Oral evaluations 0% Not Covered X-rays 0% Not Covered Cleanings (prophylaxis) 0% Not Covered Fluoride treatments 0% Not Covered Sealants 0% Not Covered Space Maintainers 0% Not Covered Palliative treatment 50% Not Covered Fillings 50% Not Covered Simple extractions 50% Not Covered Denture repairs and relines/rebasing 50% Not Covered Crowns & onlays 50% Not Covered Therapeutic Pulpotomies 50% Not Covered Root canal therapy 50% Not Covered Non-surgical periodontal services 50% Not Covered Surgical periodontal services 50% Not Covered Periodontal maintenance 50% Not Covered Fixed bridges and dentures 50% Not Covered Implants 50% Not Covered Oral surgery services 50% Not Covered General anesthesia or IV sedation - dental office 50% Not Covered Biopsies 50% Not Covered Occlusal (night) guards 50% Not Covered Orthodontic services (braces) - when medically necessary. 50% Not Covered Inpatient/outpatient/in your home 0% - After deductible Not Covered
Dental Services - Accidental Injury (Emergency. Emergency room - When services are due to accidental injury to sound natural teeth. $200 The level of coverage is the same as network provider. In a physician’s/dentist’s office - When services are due to accidental injury to sound natural teeth. $50 20% - After deductible Services connected to dental care when performed in an outpatient facility * 0% - After deductible 20% - After deductible Inpatient/outpatient/in your home 0% - After deductible 20% - After deductible
Dental Services - Accidental Injury (Emergency. Emergency room - When services are due to accidental injury to sound natural teeth. $300 The level of coverage is the same as network provider. In a physician’s/dentist’s office - When services are due to accidental injury to sound natural teeth. $50 20% - After deductible Services connected to dental care when performed in an outpatient facility * 0% - After deductible 20% - After deductible Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Dental Care (Pediatric) - for members under age 19 See Dental Services in Section 3 for benefit limits and details. These services only apply to an enrolled member under the age of 19. Oral evaluations 0% 0% X-rays 0% 0% Cleanings (prophylaxis) 0% 0% Fluoride treatments 0% 0% Sealants 0% 0% Space Maintainers 0% 0% Palliative treatment 50% 50% Fillings 50% 50% Simple extractions 50% 50% Denture repairs and relines/rebasing 50% 50% Crowns & onlays 50% 50% Therapeutic Pulpotomies 50% 50% Root canal therapy 50% 50% Non-surgical periodontal services 50% 50% Surgical periodontal services 50% 50% Periodontal maintenance 50% 50% Fixed bridges and dentures 50% 50% Implants 50% 50% Oral surgery services 50% 50% General anesthesia or IV sedation - dental office 50% 50% Biopsies 50% 50% Occlusal (night) guards 50% 50% Orthodontic services (braces) - when medically necessary. 50% 50% Inpatient/outpatient/in your home 0% - After deductible 20% - After deductible Durable Medical Equipment (DME), Medical Supplies, Diabetic Supplies, Prosthetic Devices, and Enteral Formula or Food, Hair Prosthetics Outpatient durable medical equipment* - Must be provided by a licensed medical supply provider. 0% - After deductible 20% - After deductible Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 0% - After deductible 20% - After deductible Outpatient diabetic supplies/equipment purchased at licensed medical supply provider (other than a pharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacy. 0% - After deductible 20% - After deductible Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 0% - After deductible 20% - After deductible Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 0% - After deductible 20...
Dental Services - Accidental Injury (Emergency. Emergency room - When services are due to accidental injury to sound natural teeth. 0% - After deductible The level of coverage is the same as network provider. In a physician’s/dentist’s office - When services are due to accidental injury to sound natural teeth. 0% - After deductible 40% - After deductible Services connected to dental care when performed in an outpatient facility * 0% - After deductible 40% - After deductible Inpatient/outpatient/in your home 0% - After deductible 40% - After deductible Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay
Dental Services - Accidental Injury (Emergency. Emergency room - When services are due to accidental injury to sound natural teeth. $100 The level of coverage is the same as network provider. In a physician’s/dentist’s office - When services are due to accidental injury to sound natural teeth. $25 20% - After deductible Services connected to dental care when performed in an outpatient facility * 0% - After deductible 20% - After deductible Inpatient/outpatient/in your home 0% - After deductible 20% - After deductible Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay
Dental Services - Accidental Injury (Emergency. Emergency room - When services are due to accidental injury to sound natural teeth. $150 The level of coverage is the same as network provider. In a physician’s/dentist’s office - When services are due to accidental injury to sound natural teeth. $40 Not Covered Services connected to dental care when performed in an outpatient facility * Standard $750 - After deductible Not Covered Enhanced $375 Not Covered Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Inpatient/outpatient/in your home 0% - After deductible Not Covered
Dental Services - Accidental Injury (Emergency. Emergency room - When services are due to accidental injury to sound natural teeth. 10% - After deductible The level of coverage is the same as network provider. Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Care Coordinated by Your Primary Care Provider and permitted Self-Referrals Non-network Providers
Dental Services - Accidental Injury (Emergency. Emergency room - When services are due to accidental injury to sound natural teeth. $150 The level of coverage is the same as network provider. In a physician’s/dentist’s office - When services are due to accidental injury to sound natural teeth. $40 Not Covered Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Services connected to dental care when performed in an outpatient facility * Standard $750 - After deductible Not Covered Enhanced $375 Not Covered Inpatient/outpatient/in your home 0% - After deductible Not Covered
