Diagnostic and Preventive Services. Routine Oral Exams and Consultations Comprehensive and periodic evaluations are limited to two (2) every twelve (12) months Once a comprehensive evaluation is paid, the Member is not eligible to undergo the same service with the same Provider, unless there is a significant change in health condition or the Member is absent from the Provider for 3 or more years. Detailed problem-focused evaluations are limited to one (1) every twelve (12) months per eligible diagnosis. Limited problem-focused evaluations are limited to one (1) every twelve (12) months. Consultations are diagnostic services provided by a Dentist or physician other than the practitioner providing the dental treatment, and are limited to one (1) every twelve (12) months. Oral Radiographs (x-rays) Complete series intraoral x-rays or panoramic film x-rays, limited to one (1) film every five (5) years. Bitewing x-rays, limited to one (1) set every twelve (12) months for Members under age 19, and one (1) set every eighteen (18) months for Members ages 19 and older. Periapical intraoral films limited to four (4) every twelve (12) months per Provider if not performed in conjunction with definitive procedures. Occlusal intraoral films limited for Members under age 8, and limited to two (2) every twelve (12) months. Oral Cleanings (Prophylaxis) Limited to two (2) every twelve (12) months. One additional cleaning during the Policy Year will be allowed for Members that are under the care of a medical professional during pregnancy Fluoride Treatment Limited to Members under age 14, and Limited to one (1) every twelve (12) months. Sealants Limited to children under 16 years old, and only for permanent first and secondary molars, and Limited to one per tooth every three (3) years. Emergency (Palliative) Treatment Limited to 2 per 12 months in combination with pulpal debridement B. Basic Services Space Maintainers Limited to Members under age 14. Covered when used to maintain space as a result of prematurely lost deciduous molars and permanent first molars or deciduous molars and permanent first molars that have not, or will not, develop. Limited to one (1) every five (5) years. Basic Restorations (amalgam and resin) Replacement of restorative services only covered when they are not and cannot be made serviceable. Basic restorations will not be covered if replaced within twenty four (24) months of previous placement of any basic restoration. Prefabricated stainless steel crowns are included under this coverage, limited to Members under age fourteen (14), and limited to one (1) for each tooth per lifetime. Endodontic (Pulpal) Therapy Eligible teeth limited to primary anterior teeth when there is no permanent tooth to replace it. Limited to one (1) per eligible tooth per lifetime. Root Canal Limited to one (1) per tooth per lifetime. Non-Surgical Periodontics Periodontal scaling and root planing limited to one (1) every twenty four (24) months for each area of the mouth.
Appears in 1 contract
Samples: Limited Benefit Contract
Diagnostic and Preventive Services. Routine Oral Exams and Consultations Comprehensive and periodic evaluations are limited to two (2) every twelve (12) months Once a comprehensive evaluation is paid, the Member is not eligible to undergo the same service with the same Provider, unless there is a significant change in health condition or the Member is absent from the Provider for 3 three (3) or more years. Detailed problem-focused evaluations are limited to one (1) every twelve (12) months per eligible diagnosis. Limited problem-focused evaluations are limited to one (1) every twelve (12) months. Consultations are diagnostic services provided by a Dentist dentist or physician other than the practitioner providing the dental treatment, and are limited to one (1) every twelve (12) months. Oral Radiographs (x-rays) Complete series intraoral x-rays or panoramic film x-rays, limited to one (1) film every five (5) years. Bitewing x-rays, limited to one (1) set every twelve (12) months for Members under age nineteen (19), and one (1) set every eighteen (18) months for Members ages 19 nineteen (19) and older. Periapical intraoral films limited to four (4) every twelve (12) months per Provider if not performed in conjunction with definitive procedures. Occlusal intraoral films limited for Members under age 8eight (8), and limited to two (2) every twelve twenty- four (1224) months. Oral Cleanings (Prophylaxis) Limited to two (2) every twelve (12) months. One additional cleaning during the Policy Year will be allowed for Members that are under the care of a medical professional during pregnancy pregnancy Fluoride Treatment Limited to Members under age fourteen (14), and Limited to one (1) every twelve (12) months. Sealants Limited to children under 16 sixteen (16) years old, and only for permanent first and secondary molars, and Limited to one (1) per tooth every three (3) years. Emergency (Palliative) Treatment Limited to 2 two (2) per 12 months twelve (12) months, in combination with pulpal debridement B. Basic Services Application of Medicine to stop Cavities Two (2) treatments per twelve (12) months for members between ages one (1) and six (6) One (1) treatment per twelve (12) months for members between ages seven (7) and twelve (12) Space Maintainers Limited to Members under age fourteen (14). Covered when used to maintain space as a result of prematurely lost deciduous molars and permanent first molars or deciduous molars and permanent first molars that have not, or will not, develop. Limited to one (1) every five (5) years. Basic Services Basic Restorations (amalgam and posterior resin) Replacement of restorative services only covered when they are not and cannot be made serviceable. Basic restorations will not be covered if replaced within twenty twenty-four (24) months of previous placement of any basic restoration. Prefabricated stainless steel crowns are included under this coverage, limited to Members under age fourteen (14), and limited to one (1) for each tooth per lifetime. Endodontic (Pulpal) Therapy Eligible teeth limited to primary anterior teeth when there is no permanent tooth to replace it. Limited to one (1) per eligible tooth per lifetime. Root Canal Limited to one (1) per tooth per lifetime. Non-Surgical Periodontics Periodontics Periodontal scaling and root planing limited to one (1) every twenty four thirty-six (2436) months for each area of the mouth. Periodontal maintenance following active periodontal therapy limited to two (2) every twelve (12) months in addition to routine Prophylaxis. Surgical Periodontics Surgical periodontal procedures limited to one (1) every thirty-six (36) months for each area of the mouth. Guided tissue regeneration limited to one (1) for each tooth per lifetime. Full mouth debridement limited to one (1) per lifetime. Gingivectomy or gingivoplasty, limited to one every thirty-six (36) months; Gingival flap procedure limited to one every thirty-six (36) months; Clinical crown lengthening, limited to one (1) for each tooth per lifetime; Osseous surgery, limited to one every thirty-six (36) months; Pedicle soft tissue graft, limited to one every thirty-six (36) months; Free soft tissue graft, limited to one every thirty-six (36) months; Subepithelial connective tissue graft, limited to one every thirty-six (36) months. Simple Extractions Surgical Extractions Surgical removal of erupted tooth with elevation of mucoperiosteal flap and removal of bone and/or section of tooth. Oral Surgery Removal of impacted tooth; Surgical removal of residual tooth roots; Coronectomy-intentional partial tooth removal; Tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth; Surgical access to an unerupted tooth; Alveoloplasty in conjunction with extraction; Removal of exostosis; Excision of pericoronal gingiva. General Anesthesia/Sedation If used in conjunction with certain eligible oral surgery services. Limited to sixty (60) minutes per session. Crown Repairs Recementation, restoration and pin retention Limited to one (1) every three (3) years. During the first twelve (12) months following insertion of any preventive, restorative or prosthodontics service by the same Provider, this benefit is considered included in the preventive, restorative or prosthodontics service benefit. Adjustments and Repairs of Prosthetics Major Services Prosthetic Dentures and Bridges Complete, Fixed or Removable Partial Dentures Limited to one (1) every five (5) years. Other Prosthetic Services Denture relining, rebasing or adjustments are considered part of the denture charges if provided within six (6) months of insertion by the same Provider. Subsequent denture relining or rebasing are limited to one (1) every three (3) years thereafter. Recementation or repair of fixed partial denture. Limited to one (1) every three (3) years. Recementation during the first twelve (12) months following insertion of any preventive, restorative or prosthodontics service by the same Provider will be considered part of the corresponding preventive, restorative or prosthodontics Benefit, and will not be covered under this Other Prosthetic Services section. Replacement of natural tooth/teeth in an arch will not be covered within five (5) years of a fixed partial denture, full denture or partial removable denture. Inlays, Onlays and Crowns Crowns, inlays, onlays, core buildup including pins, and prefabricated post and core. All limited to one (1) per tooth every five (5) years. Single crowns, inlays and onlays, and buildups, post and cores, will not be covered within five (5) years of previous placement of any of the procedures in this category. Dental Implants If shown as included in the Schedule of Dental Benefits, Dental Implant services are limited to Members age eighteen (18) and older, and to one (1) service per tooth or tooth area per lifetime. Coverage includes: Surgical placement of endosteal, eposteal and transosteal implants. Implant removal. Debridement of periimplant defects and osseous contouring surrounding a single implant, and surface cleaning of the exposed implant surfaces, including flap entry and closure. Bone graft. Supporting structures: Connecting bar, Prefabricated abutment, Custom fabricated abutment. Abutment supported removable dentures. Abutment supported fixed dentures. Abutment supported single crowns. Implant supported single crowns. Abutment supported fixed partial dentures. Autogenous or nonautogenous osseous, esteoperioesteal or cartilage graft of the mandible or maxilla. Sinus augmentation with bone or bone substitutes via lateral open approach or vertical approach. Bone replacement graft for ridge preservation. Orthodontic Services If shown as included in the Schedule of Dental Benefits, this Benefit Plan will cover Orthodontic Services. Orthodontic Services may be limited to Members under age nineteen (19) only, if so established in the Schedule of Dental Benefits. Orthodontic Services will be subject to the Lifetime Maximum Orthodontic Benefit stated in the Schedule of Dental Benefits. Once this Benefit Plan has paid Benefits up to such Lifetime Maximum for a Member, no more Orthodontic Services Benefits will be payable for the life of that Member. The Orthodontic Services Benefits will not count towards the Annual Maximum Benefit. Pre-authorization is required for Orthodontic Services to be covered. An explanation of the plan of treatment must be submitted to Claims Administrator. Upon review of the information, Claims Administrator will notify You and Your Provider of the reimbursement schedule, frequency of payment over the course of the treatment, and Your share of the cost. Benefits include services for limited, interceptive and comprehensive Orthodontic treatment of the primary, transitional and adolescent dentition in addition to removable and fixed appliance therapy. Treatment visits are provided for pre-orthodontic, periodic orthodontic and orthodontic retention. Payments are made quarterly. Payment for Orthodontic Services will cease at the end of the month of the termination of this Benefit Plan.
Appears in 1 contract
Samples: Limited Benefit Contract
Diagnostic and Preventive Services. Routine Oral Exams and Consultations Comprehensive and periodic evaluations are limited to two (2) every twelve (12) months Once a comprehensive evaluation is paid, the Member is not eligible to undergo the same service with the same Provider, unless there is a significant change in health condition or the Member is absent from the Provider for 3 three (3) or more years. Detailed problem-focused evaluations are limited to one (1) every twelve (12) months per eligible diagnosis. Limited problem-focused evaluations are limited to one (1) every twelve (12) months. Consultations are diagnostic services provided by a Dentist or physician other than the practitioner providing the dental treatment, and are limited to one (1) every twelve (12) months. Oral Radiographs (x-rays) Complete series intraoral x-rays or panoramic film x-rays, limited to one (1) film every five (5) years. Bitewing x-rays, limited to one (1) set every twelve (12) months for Members under age nineteen (19), and one (1) set every eighteen (18) months for Members ages 19 nineteen (19) and older. Periapical intraoral films limited to four (4) every twelve (12) months per Provider if not performed in conjunction with definitive procedures. Occlusal intraoral films limited for Members under age 8, and limited to two (2) every twelve (12) months. Oral Cleanings (Prophylaxis) Limited to two (2) every twelve (12) months. One additional cleaning during the Policy Year will be allowed for Members that are under the care of a medical professional during pregnancy pregnancy Fluoride Treatment Limited to Members under age fourteen (14), and Limited to one (1) every twelve (12) months. Sealants Limited to children under 16 sixteen (16) years old, and only for permanent first and secondary molars, and Limited to one per tooth every three (3) years. Emergency (Palliative) Treatment Limited to 2 two (2) per 12 twelve (12) months in combination with pulpal debridement B. Basic Services Space Maintainers Limited to Members under age 14. Covered when used to maintain space as a result of prematurely lost deciduous molars and permanent first molars or deciduous molars and permanent first molars that have not, or will not, develop. Limited to one (1) every five (5) years. Basic Restorations (amalgam and resin) Replacement of restorative services only covered when they are not and cannot be made serviceable. Basic restorations will not be covered if replaced within twenty four (24) months of previous placement of any basic restoration. Prefabricated stainless steel crowns are included under this coverage, limited to Members under age fourteen (14), and limited to one (1) for each tooth per lifetime. Endodontic (Pulpal) Therapy Eligible teeth limited to primary anterior teeth when there is no permanent tooth to replace it. Limited to one (1) per eligible tooth per lifetime. Root Canal Limited to one (1) per tooth per lifetime. Non-Surgical Periodontics Periodontal scaling and root planing limited to one (1) every twenty four (24) months for each area of the mouth.debridement
Appears in 1 contract
Samples: Limited Benefit Contract
Diagnostic and Preventive Services. Routine Oral Exams and Consultations Comprehensive and periodic evaluations are limited to two (2) every twelve (12) months Once a comprehensive evaluation is paid, the Member is not eligible to undergo the same service with the same Provider, unless there is a significant change in health condition or the Member is absent from the Provider for 3 or more years. Detailed problem-focused evaluations are limited to one (1) every twelve (12) months per eligible diagnosis. Limited problem-focused evaluations are limited to one (1) every twelve (12) months. Consultations are diagnostic services provided by a Dentist dentist or physician other than the practitioner providing the dental treatment, and are limited to one (1) every twelve (12) months. Oral Radiographs (x-rays) rays) Complete series intraoral x-rays or panoramic film x-rays, limited to one (1) film every five (5) years. Bitewing x-rays, limited to one (1) set every twelve (12) months for Members under age 19, and one (1) set every eighteen (18) months for Members ages 19 and older. Periapical intraoral films limited to four (4) every twelve (12) months per Provider if not performed in conjunction with definitive procedures. Occlusal intraoral films limited for Members under age 8, and limited to two (2) every twelve (12) months. Oral Cleanings (Prophylaxis) Limited to two (2) every twelve (12) months. One additional cleaning during the Policy Year will be allowed for Members that are under the care of a medical professional during pregnancy Fluoride Treatment Limited to Members under age 14, and Limited to one (1) every twelve (12) months. Sealants Limited to children under 16 years old, and only for permanent first and secondary molars, and Limited to one per tooth every three (3) years. Emergency (Palliative) Treatment Limited to 2 per 12 months in combination with pulpal debridement B. Basic Services Space Maintainers Limited to Members under age 14. Covered when used to maintain space as a result of prematurely lost deciduous molars and permanent first molars or deciduous molars and permanent first molars that have not, or will not, develop. Limited to one (1) every five (5) years. Basic Restorations (amalgam and resin) Replacement of restorative services only covered when they are not and cannot be made serviceable. Basic restorations will not be covered if replaced within twenty four (24) months of previous placement of any basic restoration. restoration. Prefabricated stainless steel crowns are included under this coverage, limited to Members under age fourteen (14), and limited to one (1) for each tooth per lifetime. Endodontic (Pulpal) Therapy Eligible teeth limited to primary anterior teeth when there is no permanent tooth to replace it. Limited to one (1) per eligible tooth per lifetime. Root Canal Limited to one (1) per tooth per lifetime. Non-Surgical Periodontics Periodontal scaling and root planing limited to one (1) every twenty four (24) months for eac h area of the mouth. Periodontal maintenance following active periodontal therapy limited to two (2) every twelve (12) months in addition to routine Prophylaxis. Surgical Periodontics Surgical periodontal procedures limited to one (1) every thirty six (36) months for each area of the mouth.. Guided tissue regeneration limited to one (1) for each tooth per lifetime. Gingivectomy or gingivoplasty, limited to one every thirty six (36) months; Gingival flap procedure limited to one every thirty six (36) months; Clinical crown lengthening, limited to one (1) for each tooth per lifetime; Osseous surgery, limited to one (1) every thirty six (36) months; Pedicle soft tissue graft, limited to one every 36 months; Free soft tissue graft, limited to one every 36 months; Subepithelial connective tissue graft, limited to one every 36 months; Full mouth debridement to enable comprehensive evaluation and diagnosis, limited to one (1) per lifetime. Simple Extractions Surgical Extractions Surgical removal of erupted tooth with elevation of mucoperiosteal flap and removal of bone and/or section of tooth. Oral Surgery Removal of impacted tooth; Surgical removal of residual tooth roots; Coronectomy-intentional partial tooth removal; Tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth; Surgical access to an unerupted tooth; Alveoloplasty in conjunction with extraction; Removal of exostosis; Excision of pericoronal gingiva. General Anesthesia/Sedation If used in conjunction with certain eligible oral surgery services. Limited to sixty (60) minutes per session. Crown Repairs Recementation, restoration and pin retention Limited to one (1) every three (3) years. During the first twelve (12) months following insertion of any preventive, restorative or prosthodontics service by the same Provider, this benefit is considered included in the preventive, restorative or prosthodontics service benefit. Adjustments and Repairs of Prosthetics
Appears in 1 contract
Samples: Limited Benefit Contract
