Dental
Implants
Benefits
are provided for services and supplies provided by an oral surgeon or physician
for dental implants. Services and supplies are covered at 50 percent with a
lifetime
maximum of $1,000. If expenses exceed this $1,000 lifetime maximum, this plan
will not pay the additional costs. These expenses are not subject to the $200
annual deductible or $2,300 annual coinsurance maximum.
For the purpose of this plan,
dental implants refer to a device(s) inserted into or onto the maxilla (upper
jaw bone) or mandible (lower jaw bone) to retain or support a dental prosthesis.
A dental implant is considered acceptable treatment when clear clinical evidence
shows a conventional fixed or removable prosthesis cannot provide clinically
acceptable treatment. If dental implant treatment is elected when a conventional
fixed or removable prosthesis provides acceptable clinical treatment, an
allowance for the implant will be provided based on the appropriate amount in
the Dental Fee Schedule, paid at 50 percent.
Covered services and supplies
include:
- Hospital
services and supplies and the administration of general anesthesia.
- The
placement, repair or removal of endosseous, transosseous or subperiosteal
implants, including connectors.
- Temporary
appliances placed during the “no load” healing period (after
implants are surgically placed and prior to the permanent superstructure) when
performed in conjunction with implants.
- Alveolar
ridge augmentation by surgical placement of osseous bone grafts and/or guided
tissue regeneration, and/or vestibulo-plasty when performed in conjunction with
implants.
Preauthorization
– Dental Implants
You
must preauthorize dental implant benefits with the Trust
Office. To preauthorize benefits, your
physician or oral surgeon must submit to the Trust Office a written description
of the indications for treatment, the treatment plan with supportive x-rays and
his or her usual fees for the treatment. The Trust Office will evaluate this
material and provide you and your physician or oral surgeon an estimate of
benefits payable under this plan. If you receive treatment without
preauthorization, the Trust Office may deny all or a part of the charges and may
request a post-treatment review (which includes a review of x-rays and chart
notes) as a condition of receiving benefits. You are responsible for any fees
assessed by the physician or oral surgeon for a post-treatment review.
Exclusions
– Dental Implants
Benefits are
not
provided for:
- Tooth
transplantation or implantation.
- Permanent
prosthetics (e.g., crowns, bridges, partials, or dentures) placed in conjunction
with implants, except as provided for under Scheduled Dental
Benefits.
- Services
started before the patient was eligible under this plan or services rendered
after termination of eligibility.
- Services
or supplies subject to General Limitations and
Exclusions.
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