Individual & Family Plans dental coverage

Pediatric check-up care for children

The following pediatric dental services are covered for members under age 19:

  • Periodic oral evaluation – one every six months
  • Limited oral evaluation – one every six months
  • Oral evaluation – one every six months
  • Periodontal evaluation – one every six months
  • Dental x-rays – complete series (including bitewings) – one every 60 months
  • Dental x-rays – periapical and occlusal films
  • Bitewings – one set every six months
  • Vertical bitewings – seven to eight films – one set every six months
  • Panoramic film – one film every 60 months
  • Cephalometric radiographic image
  • Oral / Facial photographic images
  • Interpretation of diagnostic image
  • Diagnostic models
  • Prophylaxis – one every six months
  • Topical application of fluoride (excluding prophylaxis) – two every 12 months
  • Sealant – per tooth – unrestored permanent molars – one sealant per tooth every 36 months
  • Space maintainers – fixed and removable – unilateral and bilateral
  • Re-cementing space maintainer

For dental services provided by non-network providers, you pay 50 percent after the non-network deductible has been met.

Major dental care for children

The following pediatric dental services are covered for members under age 19.

Restorative services:

  • Amalgam and resin-based composite filings
  • Root canal
  • Extractions
  • Periodontal scaling and root planing once every 24 months
  • Full mouth debridement once per lifetime
  • Crowns – limited to one per tooth, per 60 months
  • Some inlays and onlays – one per tooth, per 60 months
  • Complete and partial dentures, bridges – limited to one in a 60 month period, adjustments, repairs, relines, and rebases, every 36 months
  • Some complex oral surgery
  • Implants – one every 60 months

The following dental services are not covered:

  • Services from non network providers.
  • Dental services for members 19 and older.
  • Temporary services (e.g. provisional crowns, interim dentures, et al.)

Orthodontia for children

The following pediatric dental services are covered for members under age 19:

  • Orthodontics to help restore oral structures to health and function and to treat serious medical conditions such as:
    • cleft palate and cleft lip
    • maxillary/mandibular micrognathia (underdeveloped upper or lower jaw)
    • extreme mandibular prognathism
    • severe asymmetry (craniofacial anomalies)
    • ankylosis of the temporomandibular joint
    • and other major skeletal dysplasias

The following dental services are not covered:

  • Services from non network providers.
  • Cosmetic services, such as appliances and braces to improve the appearance of the teeth.
  • Orthodontia services for members 19 and older.


U5362 04/2020