Preventive cleaning (periodontal cleaning in the presence of inflamed gums is considered to be a Basic Benefit for payment purposes), topical application of fluoride solutions, space maintainers.
Preventive Drugs When purchased at any pharmacy: Must be prescribed by a physician. See Prescription Drug section for details. $0 Not Covered Nicotine Replacement Therapy (NRT) and Smoking Cessation Prescription Drugs When purchased at any pharmacy: Must be prescribed by a physician. See Prescription Drug section for details. Tier 1 Preventive: $0 Tier 1 Non-preventive: $10 - After deductible Not Covered Tier 2 Preventive: $0 Tier 2 Non-preventive: $45 - After deductible Not Covered Tier 3: $70 - After deductible Not Covered Tier 4: $90 - After deductible Not Covered Tier 5: NRT and Smoking Cessation drugs are only placed in Tier 1, Tier 2, Tier 3, or Tier 4. See above. Not Covered When purchased at a Mail Order Pharmacy: Not Covered Not Covered
Preventive Care This plan covers preventive care as described below. “
Laboratory a. Drug tests shall be conducted by laboratories licensed and approved by SAMSHA which comply with the American Occupational Medical Association (AOMA) ethical standards. Upon advance notice, the parties retain the right to inspect the laboratory to determine conformity with the standards described in this policy. The laboratory will only test for drugs identified in this policy. The City shall bear the cost of all required testing unless otherwise specified herein. b. Tests for all controlled substances, except alcohol, shall be by oral fluid testing and shall consist of two procedures, a screen test and, if that is positive, a confirmation test. c. To be considered positive for reporting by the laboratory to the City, both samples must be tested separately in separate batches and must also show positive results on the confirmatory test. d. In the event of a positive test, the testing laboratory will perform an automatic confirmation test on the original specimen at no cost to the Covered Employee. In addition, the testing laboratory shall preserve a sufficient specimen to permit an independent re-testing at the Covered Employee’s request and expense. The same, or any other, approved laboratory may conduct re-tests. The laboratory shall endeavor to notify the designated MRO of positive drug, alcohol, or adulterant tests results within five (5) working days after receipt of the specimen.
Medically Necessary In general, We will not Cover any dental service, procedure, treatment, test or device that We determine is not Medically Necessary. If an External Appeal Agent certified by the State overturns Our denial, however, We will Cover the service, procedure, treatment, test or device for which coverage has been denied, to the extent that such service, procedure, treatment, test or device, is otherwise Covered under the terms of this Contract.