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Variations from Standard Benefit Plans

Please refer to the policy approved in your state for specific details. In the event of a discrepancy between items listed below and your policy, the policy will control. Contact your sales representative for additional details or to review policy documents.

AZ: Coverage for certain prescription drugs related to dental services is available upon request.

CO: Orthodontic treatment for cleft lip or cleft palate are covered services when medically necessary.

MD: Prophylaxis (cleanings) are limited to one service per 120 days. Fluoride treatment is limited to one service per 120 days under a certain age; refer to policy documents for age restriction. Oral evaluations (exams) are limited to one service per 120 days. Detailed problem focused exams are eligible for one service per 120 days per eligible diagnosis.

MN: Plans include coverage for certain services related to the treatment of temporomandibular joint and craniomandibular joint disorder are covered services with any policy issued in Minnesota.

MT:

  1. Oral Evaluations:
    • Comprehensive and periodic – two (2) of these services per 12 months. Once paid, comprehensive evaluations are not eligible to the same office unless there is a significant change in health condition or the patient is absent from the office for three (3) or more year(s).
    • Limited problem focused and consultations – one (1) of these services per dentist per patient per 12 months.
    • Detailed problem focused – one (1) per dentist per patient per 12 months per eligible diagnosis.
  2. Prophylaxis – two (2) per 12 months. One (1) additional for Members under the care of a medical professional during pregnancy.
  3. Fluoride treatment – one (1) per 12 months under age fourteen (14).
  4. Periodontal maintenance following active periodontal therapy – two (2) per 12 months in addition to routine prophylaxis.
  5. Periodontal scaling and root planing – one (1) per 36 months per area of the mouth.

NM: Plans include coverage for certain services related to the treatment of temporomandibular joint and craniomandibular joint disorder for any policy issued in New Mexico. Coinsurance values listed in quotes requested by prospective clients show the company responsibility. Please see your plan documents for a listing of covered services which list member coinsurance responsibility.