o When covered, localized delivery of antimicrobial agents is limited to two teeth per quadrant and up to two times (per tooth) in a benefit period. o When covered, localized delivery of antimicrobial agents must be preceded by scaling and root planing done a minimum of six weeks and a maximum of six months prior to treatment, or the patient must have been in active supportive periodontal therapy. Note: Some benefits are available only under certain conditions of oral health. It is strongly recommended that you have your dentist submit a Confirmation of Treatment and Cost request to determine if the treatment is a covered dental benefit. A Confirmation of Treatment and Cost is not a guarantee of payment. See the “Confirmation of Treatment and Cost” section for additional information. Class II Endodontics Covered Dental Benefits — Procedures for pulpal and root canal treatment, services covered include: o Pulp exposure treatment o Pulpotomy o Apicoectomy — Refer to “Class II Sedation” for Sedation information. Limitations — Re-treatment of the same tooth is Not a Paid Covered Dental Benefit when performed within two years of the previous root canal treatment. — Refer to Class III Prosthodontics if the root canals are placed in conjunction with a prosthetic appliance. Exclusions — Bleaching of teeth ***Refer Also To General Limitations and Exclusions*** Class III Benefits Note: The subscriber should consult the provider regarding any charges that may be the patient’s responsibility before treatment begins. Note: Some benefits are available only under certain conditions of oral health. It is strongly recommended that you have your dentist submit a Confirmation of Treatment and Cost request to determine if the treatment will be covered. Class III Periodontic Services Covered Dental Benefits — Under certain conditions of oral health, services covered are: o Occlusal guard (nightguard) o Repair and relines of occlusal guard o Complete occlusal equilibration Note: These benefits are available only under certain conditions of oral health. It is strongly recommended that you have your dentist submit a Confirmation of Treatment and Cost request to determine if the treatment is a covered dental benefit. A Confirmation of Treatment and Cost is not a guarantee of payment. See the “Confirmation of Treatment and Cost” section for additional information. 2024-01-03000-BB 14 LG PPOL 20240101