The Dental Plans pay benefits for preventive, basic and major dental care provided by a licensed dentist or doctor (or a dental assistant or hygienist working under the direct supervision of a dentist). The plans also provide coverage for orthodontia treatment, either for dependent children only or for both adults and dependent children.
To be eligible for benefits, the dental services and supplies must (for the condition being treated) be:
· Performed or prescribed by a licensed dentist.
· Necessary based on generally accepted dental standards.
The benefits payable under each of the plans are outlined below. Note the deductibles, coinsurance and benefit maximums are the same for network providers and out-of-network providers. However, charges for network providers are discounted, lowering your total cost. For additional details, you are encouraged to contact Aetna or MetLife.
Preventive Care
To promote good dental health, the dental options cover 100% of the cost of diagnostic and preventive services, with no deductible or copayments. The following services are considered to be diagnostic or preventive:
· Office visit during regular office hours, for oral examinations.
○ Routine comprehensive or recall examination (limited to 2 visits per calendar year); and
○ Problem-focused examination (unlimited).
· Prophylaxis (cleaning) (limited to 2 treatments per calendar year).
· Topical application of fluoride (limited to one course of treatment per calendar year and to children under age 19).
· Sealants on permanent teeth (limited to one application per tooth for children age 6 up to age 14).
· Bitewing X-rays (limited to 2 per calendar year).
· Complete X-ray series, including bitewings if necessary, or panoramic film (limited to 1 set every 60 months).
· Vertical bitewing X-rays (limited to 2 per calendar year).
· Emergency palliative treatment.
· Space maintainers, fixed or removable (up to age 19).
Basic Care
The following services are considered basic care:
· Visits and exams—Professional visit after hours (payment will be made on the basis of services rendered or visit, whichever is greater).
· X-ray and pathology:
○ Periapical X-rays (single films);
○ Intra-oral, occlusal view, maxillary or mandibular;
○ Upper or lower jaw, extra-oral; and
○ Biopsy and histopathologic examination of oral tissue.
· Oral surgery:
○ Extractions
§ Exposed root or erupted tooth;
§ Coronal remnants;
§ and Surgical removal of erupted tooth/root tip.
○ Impacted teeth
§ Removal of tooth (soft tissue);
§ Removal of tooth (partially bony); and
§ Removal of tooth (completely bony).
○ Odontogenic cysts and neoplasms
§ Incision and drainage of abscess; and
§ Removal of odontogenic cyst or tumor.
○ Other surgical procedures
§ Alveoplasty, in conjunction with extractions—per quadrant;
§ Alveoplasty, not in conjunction with extraction per quadrant;
§ Sialolithotomy: removal of salivary calculus;
§ Closure of salivary fistula;
§ Excision of hyperplastic tissue;
§ Removal of exostosis;
§ Transplantation of tooth or tooth bud;
§ Closure of oral fistula of maxillary sinus;
§ Sequestrectomy;
§ Crown exposure to aid eruption;
§ Removal of foreign body from soft tissue;
§ Frenectomy; and
§ Suture of soft tissue injury.
· Periodontics
○ Occlusal adjustment (other than with an appliance or by restoration);
○ Root planing and scaling, per quadrant (limited to 4 separate quadrants every 2 years);
○ Root planing and scaling—1 to 3 teeth per quadrant (limited to once per site every 2 years);
○ Gingivectomy per quadrant (limited to 1 per quadrant every 3 years);
○ Gingival flap procedure, per quadrant (limited to 1 per quadrant every 3 years);
○ Gingival flap procedure—1 to 3 teeth per quadrant (limited to 1 per site every 3 years);
○ Gingivectomy, 1 to 3 teeth per quadrant (limited to 1 per site every 3 years);
○ Periodontal maintenance procedures following active therapy (limited to 2 per year);
○ Osseous surgery (including flap entry and closure)—per quadrant (limited to 1 per quadrant, every 3 years);
○ Osseous surgery (including flap entry and closure)—1 to 3 teeth per quadrant (limited to 1 per site every 3 years); and
○ Soft tissue graft procedures.
· Endodontics
○ Pulp capping;
○ Pulpotomy;
○ Apexification/recalcification;
○ Apicoectomy; and
○ Root canal therapy, including necessary X-rays (limited to once per tooth per lifetime);
○ Retreatment of a root canal including treatment x-rays (limited to once per tooth per lifetime).
· General anesthesia and intravenous sedation (only when provided in conjunction with a covered surgical procedure).
· Restorative dentistry (excludes inlays, crowns—other than prefabricated stainless steel or resin—and bridges. Multiple restorations in one surface will be considered a single restoration).
○ Amalgam restorations.
○ Resin restorations.
○ Sedative fillings.
○ Pins:
§ Pin retention—per tooth, in addition to amalgam or resin restoration.
○ Crowns (when tooth cannot be restored with a filling material):
§ Prefabricated stainless steel; and
§ Prefabricated resin crown (excluding temporary crowns).
○ Recementation:
§ Inlay;
§ Crown; and
§ Bridge.
○ Full and partial denture repairs:
§ Broken dentures, no teeth involved;
§ Repair cast framework; and
§ Replacing missing or broken teeth on complete dentures, each tooth.
○ Adding teeth to existing partial denture:
§ Each tooth; and
§ Each clasp.
○ Repairs:
§ Crowns; and
§ Bridges.
○ Dentures and partials (fees for dentures and partial dentures include relines, rebases, and adjustments within six months after installation. Specialized techniques and characterizations are not eligible):
§ Office reline;
§ Laboratory reline; and
§ Rebase, per denture.
Major Care
The following services are considered major care:
· Restorative dentistry (cast or processed restorations and crowns are covered only as treatment for decay or acute traumatic injury and only when teeth cannot be restored with a filling material or when the tooth is an abutment to a fixed partial denture).
○ Inlays/onlays—metallic, porcelain or ceramic:
§ Inlay, one or more surfaces; and
§ Onlay, two or more surfaces.
○ Inlays/onlays—resin-based composite:
§ Inlay, one or more surfaces; and
§ Onlay, two or more surfaces.
○ Labial veneers:
§ Laminate—chairside;
§ Resin laminate—laboratory; and
§ Porcelain laminate—laboratory.
○ Crowns:
§ Resin;
§ Resin with noble metal and semi-precious metal;
§ Resin with base metal;
§ Porcelain;
§ Porcelain with noble metal and semi-precious metal;
§ Porcelain with base metal;
§ Base metal (full cast);
§ Noble metal and semi-precious metal (full cast); and
§ Metallic (3/4 cast).
○ Core build up, including any pins.
○ Post and core.
· Prosthodontics
○ Fixed partial denture abutments (see inlays and crowns).
○ Pontics:
§ Base metal (full cast);
§ Noble metal and semi-precious metal (full cast);
§ Porcelain with noble metal and semi-precious metal;
§ Porcelain with base metal;
§ Resin with noble metal and semi-precious metal; and
§ Resin with base metal.
○ Removable fixed partial denture (unilateral)
§ One piece casting, chrome cobalt allow clasp attachment (all types) per unit, including pontics.
○ Dentures and partials (fees for dentures and partial dentures include relines, rebases, and adjustments within six months after installation. Specialized techniques and characterizations are not eligible):
§ Complete upper denture;
§ Complete lower denture;
§ Partial upper or lower, resin base (including any conventional clasps, rests, and teeth);
§ Partial upper or lower, cast metal base with resin saddles (including any conventional clasps, rests, and teeth);
§ Stress breakers;
§ Interim partial dentures (stayplate), anterior only;
§ Special tissue conditioning, per denture; and
§ Adjustments to denture more than six months after installation;
Orthodontic Care
Covered orthodontic services include:
· Comprehensive orthodontic treatment;
· Interceptive orthodontic treatment;
· Limited orthodontic treatment;
· Post treatment stabilization;
· Appliance to correct thumb sucking.
Coverage is not provided for an orthodontic procedure if an active appliance for that orthodontic procedure was installed before the effective date of coverage.
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Questions about your employee benefits or other Human Resources issues? Contact the Workplace Solutions Center at (888) 471-2271.