Limitations — Occlusal guard (nightguard) is covered once in a three-year period from the date of service. — Repair and relines done more than six months after the date of initial placement are covered. — Complete occlusal equilibration is covered once in a lifetime. Class III Restorative Services Covered Dental Benefits — Crowns, veneers, inlays (as a single tooth restoration – with limitations) or onlays for treatment of carious lesions (visible destruction of hard tooth structure resulting from the process of removing dental decay) or fracture resulting in significant loss of tooth structure (e.g., missing cusps or broken incisal edge). — Crown buildups — Post and core on endodontically treated teeth — Implant-supported crown Limitations — A crown, veneer or onlay on the same tooth is covered once in a five-year period from the seat date. — An implant-supported crown on the same tooth is covered once in a five-year period from the original seat date of a previous crown on that same tooth. — An inlay (as a single tooth restoration) will be considered as elective treatment and an amalgam allowance will be made, with any cost difference in cost being the responsibility of the enrolled person, once in a two-year period from the seat date. — Payment for a crown, veneer, inlay, or onlay shall be paid based upon the date that the treatment or procedure is completed. — A crown buildup is covered for a non-endodontically treated posterior (back) tooth only when one cusp is missing down to, or closer than, 2mm from the gum tissue in preparation for a restorative crown. — A crown buildup is covered for an endodontically or a non-endodontically treated anterior (front) tooth only when more than 1/2 of the mesial-distal width of the incisal edge is missing down past the junction of the incisal and middle third of the tooth in preparation for a restorative crown. — A crown buildup or a post and core are covered once in a five-year period on the same tooth from the date of service. — Crown buildups or post and cores are not a paid covered benefit within two years of a restoration on the same tooth from the date of service. — A crown used for purposes of re-contouring or repositioning a tooth to provide additional retention for a removable partial denture is not a paid covered benefit unless the tooth is decayed to the extent that a crown would be required to restore the tooth whether or not a removable partial denture is part of the treatment. Exclusions — Copings — A core buildup is not billable with placement of an onlay, 3/4 crown, or veneer. — A crown or onlay is not a paid covered benefit when used to repair micro-fractures of tooth structure when the tooth is asymptomatic (displays no symptoms) or there is an existing restoration with no evidence of decay or other significant pathology. — A crown or onlay placed because of weakened cusps or existing large restorations. Class III Prosthodontics Covered Dental Benefits — Dentures 2024-01-03000-BB 15 LG PPOL 20240101