Diagnostic & Preventive Services Covered at 100%
- Routine oral exams (once per Benefit Period)
- Adult & child cleaning (once per Benefit Period)
- Bitewing x-rays
- Pulp testing
- Annual fluoride treatment (members under 19 years old)
- Sealants (members age 5 through 15)
- Palliative emergency treatment & emergency oral examinations
- Other diagnostic & preventive services
Basic Services Covered at 80%
- Routine Fillings
- Simple extractions
Major Services Covered at 50%
- Endodontics (including root canal)
- Periodontics including
- Periodontal exam and maintenance
- Gingival curettage
- Gingivectomy and gingivoplasty
- Root Planning and periodontal scaling (once per quadrant every 24 months)
- Full mouth or panoramic X-rays (once every 36 months)
- Periapical X-ray
- Surgical teeth removal and oral surgery
- Space maintainers (members under 16 years old)
- Other major services