Space Maintainers. This plan covers space maintainers for one tooth per sixty (60) month period. Space maintainers are covered: • for premature loss of primary molars and permanent first molars; or • when primary molars and permanent first molars have not or will not develop.
Space Maintainers. Limited to once per quadrant per lifetime for children up to age 16. Includes all adjustments within six months of placement. • Palliative Emergency Treatment. Limited to twice per year. • Sedative Filling. Limited to once per tooth in any 24-month period. • Amalgam or Composite Resin Restorations (fillings). Limited to once per surface per tooth every 24 months. • Periodontal Scaling and Root Planing. Limited to once per quadrant every 24 months. • Periodontal Surgery. Limited to once per quadrant in any three years. • Crown Lengthening. Limited to once per tooth per lifetime. • Root Canal Therapy. Root canal therapy limited to one initial treatment per tooth and one retreatment per tooth – for permanent teeth only. • General Anesthesia. Covered only when used in conjunction with covered oral surgical procedures. Exclusions — Below is a partial listing of non-covered services. Please see Certificate for full list: • Experimental or investigative procedures • Cosmetic dentistry • Procedures requiring appliances or restorations to alter, restore or maintain occlusion • Harmful habit appliances • Charges for lost or stolen dentures or appliances or for a duplicate prosthetic device or appliance • Prescribed drugs, pre-medication or analgesia (includes nitrous oxide) • Charges for the extraction of immature erupting third molars and nonpathologic, asymptomatic third molars • Malignancies and neoplasms and the removal of tumors, cysts, and foreign bodies • Charges for tobacco counseling, oral hygiene instruction, dietary planning or behavior management • Treatment for temporomandibular joint disorder (TMJ) • Occlusal guards, adjustments • Hospital costs • Replacement of teeth missing prior to coverage under this Plan • Services or treatments that are not medically necessary • Charges for missed or cancelled appointments • Prosthodontic services unless specifically included under Covered Services • Orthodontic services unless specifically included under Covered Services Covered Benefits Network Non-Network Vision Examination Including dilation and refraction as needed Covered once every 12 months $20 copayment Up to $42 Prescription Lenses (Pair) • Standard plastic lenses up to 55mm; and all ranges of prescriptions Covered once every 24 months • Single Vision Lenses (pair) • Bifocal Lenses (Pair) • Trifocal Lenses (Pair) $20 copayment Up to $40 Up to $60 Up to $80 Frames • Covered one every 24 months No copayment, up to $130 retail value Up to $45 Contact Lense...
Space Maintainers f. Diagnostic X-rays.
Space Maintainers a. Covered when used to maintain space as a result of prematurely lost deciduous molars and permanent first molars or deciduous molars and permanent first molars that have not , or will not, develop; and
Space Maintainers. 14. Initial installation of fixed bridgework (including inlays and crowns as abutments to replace natural teeth extracted while the individual is covered under the Plan.
Space Maintainers. When placed primarily to maintain space and not for orthodontic purposes, and provision of habit breaking appliances.
Space Maintainers. Limited to one every five year period for Members under age 14 when used to maintain space as a result of prematurely lost deciduous molars and permanent first molars, or deciduous molars and permanent first molars that have not, or will not develop. Includes:
Space Maintainers. (j) Additional dental benefits will be provided for active employees, their spouses and their eligible children under age 19, effective January 1, 1978. The Plan will pay for these additional benefits on the basis of 80% of the prevailing fee or the amount charged, whichever is less.
Space Maintainers. The plan covers all space maintainers.
Space Maintainers. Space maintainers are covered for premature loss of primary molars and permanent first molars, or for primary molars and permanent first molars that have not or will not develop. Limited to one tooth per five (5) year period.
