Page 12 - 2018 MDT Benefits & Notices

Member Driven Technologies (MDT) 2018

Dental Coverage

Members First CU MMA MetLife Dental PPO Plan
Member’s Responsibility (copays and dollar maximums)
Co-pays
- Class A – Preventive & Diagnostic services None
- Class B – Basic Restorative services 20% of approved amount
- Class C – Major Restorative services 50% of approved amount
- Class D – Orthodontic services 50% of approved amount
Dollar Maximums
- Annual Maximum (for Class I, II and III services) $2,000 per member
- Lifetime Maximum (for Class IV services) $1,000 per dependent
Class A – Preventive Services
Oral Exams 100% of approved amount, twice a calendar year
A set (up to 4 films) of bitewing x-rays
- For members age 15 and younger 100% of approved amount, one in a calendar year
- For members age 16 and older 100% of approved amount, one in a calendar year
Dental prophylaxis (teeth cleaning) 100% of approved amount, twice a calendar year
Fluoride treatment – for members age 14 and younger 100% of approved amount, twice a calendar year
Space maintainers – missing posterior (back) primary teeth –
100% of approved amount
for members age 14 and younger
Class B – Basic Services
Fillings – permanent teeth 80% of approved amount, once every 24 months
Fillings – primary (baby) teeth 80% of approved amount, once every 24 months
Panoramic or full-mouth x-rays 80% of approved amount, one every 60 months
Palliative (emergency) treatment 80% of approved amount
Diagnostic x-rays 80% of approved amount
Oral surgery including extractions 80% of approved amount
Root canal treatment – permanent tooth 80% of approved amount, once every 24 months
Scaling and root planing 80% of approved amount, once in any 24 month period per quadrant
Limited occlusal adjustments 80% of approved amount
Occlusal biteguards 80% of approved amount
General anesthesia or IV sedation 80% of approved amount
Periodontic Surgery 80% of approved amount, once in any 36 month period per quadrant
80% of approved amount, 4 perio treatments in one year. (includes 2
Periodontic maintenance
cleanings (total combo: 4)
Class C – Major Services
Onlays, crowns and veneer restorations – permanent teeth –
for members age 12 and older 50% of approved amount, once every 120 months per tooth
Recementation of crowns, veneers, inlays, onlays & bridges 50% of approved amount, once in 12 months
Relining or rebasing of a partial or complete denture 50% of approved amount
Repairs and adjustments of a partial or complete denture 50% of approved amount, once in 12 months
Tissue conditioning 50% of approved amount, once in 36 months
Occlusal Adjustments 50% of approved amount, once in 24 months
Removal dentures (complete or partial) 50% of approved amount, once in 120 months
Bridges (fixed partial dentures) – for members age 16 and
older 50% of approved amount, once in 120 months
Endosteal implants – for members age 16 and older who are
covered at the time of the actual implant placement 50% of approved amount, once per tooth in a 60 month period
Class D – Orthodontic Services – only dependents under age 19
Orthodontic Diagnostics 50% of approved amount
Orthodontic Treatment 50% of approved amount

THIS BENEFIT SUMMARY IS A BRIEF DESCRIPTION OF COMMON SERVICES. CHECK DENTAL CERTIFICATE FOR ALL
SERVICES, FREQUENCY OF SERVICES, CLASSIFICATION OF SERVICES AND WAIT PERIODS FOR SERVICES.

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