Dental & Orthodonitia Expenses

Summary of Covered Dental Expenses

Preventive Treatment
  • oral examinations, but not more than twice a year
  • cleaning and scaling of teeth, but not more than twice a year
  • full mouth x-rays, once every 36 months
  • four supplementary bitewing x-rays a year
  • application of fluoride, but not more than once a year 
Basic Treatment
  • amalgam (silver) fillings to restore decayed or accidentally broken teeth, including replacement of fillings
  • simple extractions and surgical extractions (not including impacted teeth, which are covered under the medical plan)
  • periodontal scaling (cleaning below the gum line)
  • root canal therapy
  • pulpal therapy and pulp capping
  • other surgery on the teeth except surgical removal of a tumor or cyst, or cutting and draining on abscess or cyst
  • rebasing or relining of partial or full dentures if performed more than six months after installation, but not more than once in 24 months
  • repair of crowns, inlays, onlays, partial or full dentures and fixed bridgework, to include re-cementing crowns, inlays and onlays
  • emergency dental treatment for relief of pain
  • general anesthetics and the process of administering them, including intravenous sedations when furnished for surgical procedures
  • antibiotic drug injection by dentist
Major Treatment
  • initial installation of a partial or full denture of fixed bridgework to replace a natural tooth that has been extracted (Installation includes the denture and adjustments made to it for the first six months, and fixed bridgework, including inlays and crowns needed as abutments)
  • replacement of existing or full denture, fixed bridgework or the addition of teeth to a partial denture or fixed bridgework if: the replacement or addition will replace one or more teeth; in the case of a partial denture or fixed bridgework was installed; in the case of a partial or full denture or fixed bridgework, the denture or bridgework was installed while the patient was covered under this dental plan, and replacement occurs at least five years after installation; or the denture being replaced in an immediate full denture that cannot be made permanent, and replacement by a permanent full denture occurs within 12 months from the date the immediate full denture was installed.
  • Gold fillings, crowns, inlays and onlays to restore decayed or broken teeth only when teeth cannot be restored with regular fillings
  • Replacement of gold fillings, crowns, inlays and onlays installed while the patient was covered under this plan when replacement occurs at least five years after installation or it is needed to repair or relieve an injury caused by an accident while the patient is covered under this dental plan
  • Gingival curettage (the scrapping or cleaning out of the gum pockets that surround the teeth in periodontal disease)
  • Gingivectomy (removal of infected gum tissues around the teeth)
  • Osseous (bone) surgery
  • Pedicle soft tissue grafts (gum grafts to cover exposed root)
  • Occlusal (bite) adjustments and guards
  • Other gingival (gum) surgery except surgical removal or a tumor or cyst, or cutting and draining of an abscess or cyst

Summary of Covered Orthodontic Expenses

  • complete orthodontic examination
  • cephalometric film
  • orthodontic appliance, including impressions, installation and adjustments for the first six months after installation for: minor treatment for tooth guidance; and interceptive orthodontic treatment
  • comprehensive orthodontic treatment of transitional or permanent dentition, including initial placement or the orthodontic appliance and subsequent active orthodontic treatment
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