Dental Blue RET - Covered Services

Covered Dental Services

 

You have the right to the benefits described in this section, except as limited or excluded in other sections of this Dental Blue Freedom Benefit Description.

Dental Care and Treatment

The following dental services are covered under Dental Blue Freedom only when these services are furnished by a dentist (or by a hygienist employed by the dentist), your treatment is necessary and appropriate for you and your treatment conforms to the Blue Cross and Blue Shield dental policy guidelines in effect at the time covered dental services are furnished.

Preventive Benefit Group – Group 1 Services

Dental Blue Freedom provides benefits for the following services to diagnose or prevent tooth decay and other forms of oral disease. These are the types of dental services most members receive during a routine dental check-up or visit.

Diagnostic Services

  • One complete initial oral exam, including initial dental history and charting of the teeth and supporting structures.
  • Single tooth x-rays as needed.
  • Bitewing x-rays of the crowns of the teeth (once each six months).
  • Full mouth x-rays (seven or more films, or panoramic x-ray with bitewing x-rays; once each 60 months).
  • Study models and casts used in planning treatment (once each 60 months).
  • Emergency exams.
  • Periodic or routine oral exams (once each six months).

Preventive Services

  • Routine cleaning, scaling and polishing of the teeth (once each six months).
  • Fluoride treatment for members under age 19 (once each six months).
  • Space maintainers required due to premature loss of teeth for members under age 19.
  • Sealants applied to permanent premolar and molar surfaces for members under age 14 (one application each 48 months for each premolar or molar surface).
Basic Benefit Group – Group 2 Services

Dental Blue Freedom provides benefits for the following services to: restore or remove diseased or fractured natural teeth; replace damaged or defective restorations; treat oral disease; repair, rebase or reline dentures; repair crowns and bridges; and recement crowns, inlays, onlays and fixed bridgework.

Restorative Services

  • Amalgam (silver) fillings (limited to one filling for each tooth surface in each 12 months). No benefits are provided for fillings on tooth surfaces where a sealant was applied within the last 12 months.
  • Composite resin (tooth color) fillings on front teeth (limited to one filling for each tooth surface in each 12 months). Note: On and after July 1, 2007, these benefits include single-surface composite resin fillings on back teeth. Prior to this date, the benefits for amalgam (silver) fillings will be provided toward the cost of composite resin fillings on back teeth (bicuspids and molars). You pay any balance.
  • Pin retention for fillings.
  • Stainless steel crowns on primary (baby) teeth.
  • Stainless steel crowns on first permanent (adult) molars for members under age 16.

Oral Surgery

  • Tooth extractions.
  • Root removal.
  • Biopsies.

Periodontics (Gum and Bone)

  • Periodontal scaling and root planing (once in each quadrant each 24 months).
  • Periodontal surgery (soft and hard tissue surgeries; once in each quadrant each 36 months).
  • Periodontal maintenance following active periodontal therapy (once each three months).

Endodontics (Root and Pulp)

  • Root canal therapy on permanent teeth (once in a lifetime for each tooth.)
  • Retreatment root canal therapy on permanent teeth (once in a lifetime for each tooth).
  • Therapeutic pulpotomy on primary or permanent teeth for members under age 16.
  • Other endodontic surgery intended to treat or remove the dental root.

Prosthetic Maintenance

  • Repair of partial or complete dentures, crowns and bridges (once each 12 months).
  • Adding teeth to an existing partial or complete denture.
  • Rebase or reline dentures (once each 36 months).
  • Recementing of crowns, inlays, onlays and fixed bridgework (once each 12 months).

Other Covered Services

  • Occlusal adjustments (once each 24 months).
  • Services to treat root sensitivity.
  • General anesthesia when administered in conjunction with covered surgical services.
  • Emergency dental treatment to relieve acute pain.
  • Emergency dental treatment to control a dental condition that requires immediate care to prevent permanent harm to the member.
Major Benefit Group – Group 3 Services

Dental Blue Freedom provides benefits for the following services to: replace missing teeth with artificial ones; and restore severely diseased or fractured teeth. The benefits for these covered dental services are provided only when the supporting structures are determined to be sound.

Prosthodontics (Tooth Replacement)

  • Complete or partial dentures, including services to fabricate, measure, fit and adjust them (once each 60 months for each arch).
  • Fixed bridges, including services to fabricate, measure, fit and adjust them (once each 60 months for each tooth).
  • Replacement of dentures and bridges, but only when they are installed at least 60 months after the initial placement, and only if the existing appliance cannot be made serviceable.
  • Adding teeth to an existing bridge.
  • Temporary partial dentures to replace any of the six upper or lower front teeth, but only if they are installed immediately following the loss of teeth and during the period of healing.

Major Restorative Services
(Crowns, Inlays and Onlays)

  • Crowns for members age 16 or older (once each 60 months for each tooth). Note: On and after July 1, 2007, these benefits include single-tooth dental endosteal implants (the fixture and abutment portion) when the implant replaces permanent teeth through the second molars (once each 60 months for each tooth).
  • Metallic, porcelain and composite resin inlays for members age 16 or older. The benefits for an amalgam filling will be provided toward the cost of a metallic, porcelain or composite resin inlay (once each 60 months for each tooth). You pay any balance.
  • Metallic, porcelain and composite resin onlays for members age 16 or older (once each 60 months for each tooth).
  • Replacement of crowns for members age 16 or older (once each 60 months for each tooth).
  • Replacement of metallic, porcelain and composite resin inlays for members age 16 or older. The benefits for an amalgam filling will be provided toward the cost of a metallic, porcelain or composite resin inlay (once each 60 months for each tooth). You pay any balance.
  • Replacement of metallic, porcelain and composite resin onlays for members age 16 or older (once each 60 months for each tooth).
  • Post and core or crown buildup for members age 16 or older (once each 60 months for each tooth).
Orthodontic Services

Orthodontic services are not covered under Dental Blue Freedom unless your group has purchased supplemental coverage to help pay for orthodontic services to prevent and correct misalignment of the teeth. If your group has purchased this coverage, these additional benefits are described in an Orthodontic Endorsement to this Dental Blue Freedom Benefit Description. If you have these benefits, your plan sponsor will supply you with the Orthodontic Endorsement that applies to your benefits for orthodontic services at the time you enroll for benefits under Dental Blue Freedom. Also, if a change is made to your benefits for orthodontic services, your plan sponsor can supply you with the Orthodontic Endorsement that applies to your benefits for these services. If you have an Orthodontic Endorsement that is part of Dental Blue Freedom Benefit Description, your Orthodontic Endorsement shows the amount of your lifetime benefit maximum and any age restrictions that may apply to your benefits.