Diagnostic and Preventive Services. Diagnostic and Preventive Services provided by Participating Dentists will be covered at 100%, subject to the General Limitations section and are not subject to the Calendar Year Deductible. Clinical oral examinations, - excluding emer- gency examinations, not more than once in any period of six (6) consecutive months. Dental prophylaxis - not more than once in any period of four (4) consecutive months. (Prophy- laxes performed in conjunction with fluoridation or any other procedure and periodontal prophy- laxes shall be considered as being a prophylaxis for the purpose of applying this limitation.) X-rays - Bitewing films not more than once in any period of twelve (12) consecutive months. Full mouth series (includes 10 to 14 periapical X- rays and supplementary bitewing films) not more than once in any period of thirty-six (36) consec- utive months. In applying this thirty-six (36) month limitation, a panoramic X-ray shall be considered a full mouth series. X-rays required to diagnose a specific condition that needs treatment are not subject to the limitations stated above. Diagnostic casts not more than once in any period of sixty (60) consecutive months. Working mod- els taken in conjunction with a prosthetic or other appliance are not considered to be diagnostic casts. Basic Services Anesthesia — General, or intravenous sedation only when provided in conjunction with a cov- ered oral surgical procedure. Basic Restorative Services — Amalgam restora- tions; synthetic restorations (i.e. silicate cement filling, porcelain filling, plastic filling and compo- site filling); stainless steel crowns when the tooth cannot be restored with a filling material. Palliative — Emergency treatment for relief of pain and sedative filling; other non-pain produc- ing emergent services, including recementation of inlay, onlay or partial coverage restoration, rece- mentation of cast or prefabricated post and core, recementation of crown, and recementation of fixed partial denture. Major Services These Services are covered after six months of continuous coverage under the plan, except as noted under the Waiting Period Waiver and Ex- ceptions section below. Refer to the section entitled Summary of Benefits for Blue Shield of California’s payment percent- age. Endodontics — Pulp capping; including pulpo- tomy or other palliative treatment and necessary X-rays and cultures, but excluding final restora- tion; root canal therapy; apicoectomy (including apical curettage). Oral Surgery — Extractions; removal of im- pacted teeth, radical excision of small (to 1.25 cm) non-malignant lesions; other surgical proce- dures; includes local anesthesia and routine pre and postoperative care. Periodontics — Emergency treatment including but not limited to periodontal abscess and acute periodontitis; root planing (not prophylaxis); subgingival curettage, debridement, gingival and osseous surgery (including post-surgical visits.
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Samples: Coverage and Health Service Agreement, Coverage and Health Service Agreement, Coverage and Health Service Agreement
Diagnostic and Preventive Services. Diagnostic and Preventive Services provided by Participating Dentists will be covered at 100%, subject to the General Limitations section and are not subject to the Calendar Year Deductible. Clinical oral examinations, - excluding emer- gency examinations, not more than once in any period of six (6) consecutive months. Dental prophylaxis - not more than once in any period of four (4) consecutive months. (Prophy- laxes performed in conjunction with fluoridation or any other procedure and periodontal prophy- laxes shall be considered as being a prophylaxis for the purpose of applying this limitation.) X-rays - Bitewing films not more than once in any period of twelve (12) consecutive months. Full mouth series (includes 10 to 14 periapical X- rays and supplementary bitewing films) not more than once in any period of thirty-six (36) consec- utive months. In applying this thirty-six (36) month limitation, a panoramic X-ray shall be considered a full mouth series. X-rays required to diagnose a specific condition that needs treatment are not subject to the limitations stated above. Diagnostic casts not more than once in any period of sixty (60) consecutive months. Working mod- els taken in conjunction with a prosthetic or other appliance are not considered to be diagnostic casts. Basic Services Anesthesia — General, or intravenous sedation only when provided in conjunction with a cov- ered oral surgical procedure. Basic Restorative Services — Amalgam restora- tions; synthetic restorations (i.e. silicate cement filling, porcelain filling, plastic filling and compo- site filling); stainless steel crowns when the tooth cannot be restored with a filling material. Palliative — Emergency treatment for relief of pain and sedative filling; other non-pain produc- ing emergent services, including recementation of inlay, onlay or partial coverage restoration, rece- mentation of cast or prefabricated post and core, recementation of crown, and recementation of fixed partial denture. Major Services These Services are covered after six twelve months of continuous coverage under the plan, except as noted under the Waiting Period Waiver and Ex- ceptions section below. Refer to the section entitled Summary of Benefits for Blue Shield of California’s payment percent- age. Endodontics — Pulp capping; including pulpo- tomy or other palliative treatment and necessary X-rays and cultures, but excluding final restora- tion; root canal therapy; apicoectomy (including apical curettage). Oral Surgery — Extractions; removal of im- pacted teeth, radical excision of small (to 1.25 cm) non-malignant lesions; other surgical proce- dures; includes local anesthesia and routine pre and postoperative care. Periodontics — Emergency treatment including but not limited to periodontal abscess and acute periodontitis; root planing (not prophylaxis); subgingival curettage, debridement, gingival and osseous surgery (including post-surgical visits.
Appears in 2 contracts
Samples: Coverage and Health Service Agreement, Coverage and Health Service Agreement
Diagnostic and Preventive Services. Diagnostic and Preventive Services provided by Participating Dentists will be covered at 100%, subject to the General Limitations section and are not subject to the Calendar Year Deductible. Clinical oral examinations, - excluding emer- gency examinations, not more than once in any period of six (6) consecutive months. Dental prophylaxis - not more than once in any period of four (4) consecutive months. (Prophy- laxes performed in conjunction with fluoridation or any other procedure and periodontal prophy- laxes shall be considered as being a prophylaxis for the purpose of applying this limitation.) X-rays - Bitewing films not more than once in any period of twelve (12) consecutive months. Full mouth series (includes 10 to 14 periapical X- rays and supplementary bitewing films) not more than once in any period of thirty-six (36) consec- utive months. In applying this thirty-six (36) month limitation, a panoramic X-ray shall be considered a full mouth series. X-rays required to diagnose a specific condition that needs treatment are not subject to the limitations stated above. Diagnostic casts not more than once in any period of sixty (60) consecutive months. Working mod- els taken in conjunction with a prosthetic or other appliance are not considered to be diagnostic casts. Basic Services Anesthesia — General, or intravenous sedation only when provided in conjunction with a cov- ered oral surgical procedure. Basic Restorative Services — Amalgam restora- tions; synthetic restorations (i.e. silicate cement filling, porcelain filling, plastic filling and compo- site composite filling); stainless steel crowns when the tooth cannot be restored with a filling material. Palliative — Emergency treatment for relief of pain and sedative filling; other non-pain produc- ing emergent services, including recementation of inlay, onlay or partial coverage restoration, rece- mentation of cast or prefabricated post and core, recementation of crown, and recementation of fixed partial denture. Major Services These Services are covered after six months of continuous coverage under the plan, except as noted under the Waiting Period Waiver and Ex- ceptions section below. Refer to the section entitled Summary of Benefits for Blue Shield of California’s payment percent- age. Endodontics — Pulp capping; including pulpo- tomy or other palliative treatment and necessary X-rays and cultures, but excluding final restora- tion; root canal therapy; apicoectomy (including apical curettage). Oral Surgery — Extractions; removal of im- pacted teeth, radical excision of small (to 1.25 cm) non-malignant lesions; other surgical proce- dures; includes local anesthesia and routine pre and postoperative care. Periodontics — Emergency treatment including but not limited to periodontal abscess and acute periodontitis; root planing (not prophylaxis); subgingival curettage, debridement, gingival and osseous surgery (including post-surgical visits.
Appears in 1 contract
Diagnostic and Preventive Services. Diagnostic and Preventive Services provided by Participating Dentists will be covered at 100%, subject to the General Limitations section and are not subject to the Calendar Year Deductible. Clinical oral examinations, - excluding emer- gency emergen- cy examinations, not more than once in any period peri- od of six (6) consecutive months. Dental prophylaxis - not more than once in any period of four (4) consecutive months. (Prophy- laxes performed in conjunction with fluoridation or any other procedure and periodontal prophy- laxes shall be considered as being a prophylaxis for the purpose of applying this limitation.) X-rays - Bitewing films not more than once in any period of twelve (12) consecutive months. Full mouth series (includes 10 to 14 periapical X- X-rays and supplementary bitewing films) not more than once in any period of thirty-six (36) consec- utive consecutive months. In applying this thirty-six (36) month limitation, a panoramic X-ray shall be considered a full mouth series. X-rays required to diagnose a specific condition that needs treatment are not subject sub- ject to the limitations stated above. Diagnostic casts not more than once in any period of sixty (60) consecutive months. Working mod- els taken in conjunction with a prosthetic or other appliance are not considered to be diagnostic casts. Basic Services Anesthesia — General, or intravenous sedation only when provided in conjunction with a cov- ered covered oral surgical procedure. Basic Restorative Services — Amalgam restora- tions; synthetic restorations (i.e. silicate cement filling, porcelain filling, plastic filling and compo- site filling); stainless steel crowns when the tooth cannot be restored with a filling material. Palliative — Emergency treatment for relief of pain and sedative filling; other non-pain produc- ing producing emergent services, including recementation of inlayin- lay, onlay or partial coverage restoration, rece- mentation recemen- tation of cast or prefabricated post and core, recementation of crown, and recementation of fixed partial denture. Major Services These Services are covered after six twelve months of continuous coverage under the plan, except as noted under the Waiting Period Waiver and Ex- ceptions section Exceptions sec- tion below. Refer to the section entitled Summary of Benefits for Blue Shield of California’s payment percent- age. Endodontics — Pulp capping; including pulpo- tomy or other palliative treatment and necessary X-rays and cultures, but excluding final restora- tion; root canal therapy; apicoectomy (including apical curettage). Oral Surgery — Extractions; removal of im- pacted impact- ed teeth, radical excision of small (to 1.25 cm) non-malignant lesions; other surgical proce- duresprocedures; includes local anesthesia and routine pre and postoperative care. Periodontics — Emergency treatment including but not limited to periodontal abscess and acute periodontitis; root planing (not prophylaxis); subgingival sub- gingival curettage, debridement, gingival and osseous os- seous surgery (including post-surgical visits.
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