Procedure Description Copayment Notes Dental case management – patients with special health care D9997 needs NB = Confirmation of Treatment and C Cost recommended R = Referable to a specialist TMJ = TMJ Covered GAP = Guidelines apply NB = Not a Benefit on plan OP = Optional Treatment * Coverage for general anesthesia is provided for children age 6 and under, or for children of any age with a developmental or physical disability, when medically necessary. Unlisted dental procedures and treatments that are not specifically excluded will be assigned copayments consistent with those above, based upon comparative complexity and cost. Basic Benefits The following basic benefits will be covered subject to the copayment amounts: 1. Oral Examination - Exam of the mouth and teeth. 2. Prophylaxis - Cleaning, scaling and polishing of teeth. 3. Topical Fluoride Application - Applying fluoride to the exposed tooth surface. 4. Periapical and Bitewing X-rays - Dental X-rays of the inside of the mouth. Periapical X-rays reveal the entire tooth and surrounding bone and gum tissue. Bitewing X-rays reveal some of the upper and lower teeth in the same film. 5. Extractions - The surgical removal or pulling of teeth. 6. Fillings - Silver amalgam, resin based composites or Silicate or plastic restorative material is covered. 7. Palliative Emergency Treatment - Emergency treatment primarily for relief, not cure. 8. Space Maintainers - An appliance to preserve the space between teeth caused by premature loss of a primary tooth. The primary teeth are the first teeth, sometimes known as baby teeth. 9. Repair of Dentures and Bridges - Repair or reline artificial teeth. 10. Oral Surgery - Surgery for dental purposes pertaining to the gums, teeth or tooth structure and treatment of dislocations. 11. Apicoectomy - Surgical removal of the tip of the tooth root. 12. Endodontics - The prevention, diagnosis, and treatment of diseases and injuries of the tooth pulp, root and surrounding tissue. This includes pulpotomy, pulp capping and root canal treatment. 13. Periodontic Services and Periodontic Maintenance Procedures - Services related to connective tissues around and supporting the teeth; surgical periodontic exams, gingival curettage, gingivectomy, osseous surgery including flap entry and closure, mucogingivoplastic surgery, frenectomy, periodontal grafts, root planing and curettage, and management of acute infection and oral lesions related to the tooth structure. Prosthodontic Services Dentures, bridges, partial dentures, related items — including crowns placed on dental implants — and the adjustment or repair of an existing prosthetic device are covered under this benefit. Replacement of missing teeth with full or partial dentures, crowns or bridges is limited to the charge for the standard procedure. 2024-01-03100-BB 15 DCL 20240101