Transcription of Covered Services
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Covered Services
Covered ServicesINDIVIDUAL BENEFITSP reventive Benefits PREVENTIVE AND DIAGNOSTIC SERVICESR outine oral examinations: limited to two visits each yearProphylaxis (cleaning): limited to two each yearTopical application of fluoride: limited to two treatments each year to children under age 18 Bitewing X-Rays: limited to one set each yearVertical bitewing X-Rays: limited to once every three years (7-8 films)Periapical X-Rays: limited to five films each yearFull-mouth X-Rays: limited to once every three years (complete series or panoramic)Basic BenefitsDIAGNOSTIC Services Emergency/limited oral examinations Office visit after hours: for emergencies onlyReferral consultations and examinations performed by a specialist Extraoral X-Rays Emergency palliative treatment SEALANTS & PREVENTIVE RESIN RESTORATIONSP ermanent molar teeth: limited to children under 15 years of age and once every five years per toothSPACE MAINTAINERS Space maintainer fixed, unilateral: limited to children under 19 years of ageDistal shoe space maintainer fixed, unil
Covered Services INDIVIDUAL BENEFITS Preventive Benefits PREVENTIVE AND DIAGNOSTIC SERVICES Routine oral examinations: limited to two visits each year Prophylaxis (cleaning): limited to two each year Topical application of fluoride: limited to two treatments each year to children under age 18
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