Members 21 years of age or older have a $1,000 annual emergency dental benefit per health plan year.  The annual benefit plan year runs from October 1 - September 30.  A dental emergency is an acute disorder of oral health resulting in severe pain and/or infection as a result of pathology or trauma. 

Emergency dental services* include: 

• Emergency oral diagnostic examination (limited oral examination - problem focused);
• Radiographs and laboratory services, limited to the symptomatic teeth;
• Composite resin due to recent tooth fracture for anterior teeth;
• Prefabricated crowns, to eliminate pain due to recent tooth fracture only;
• Recementation of clinically sound inlays, onlays, crowns, and fixed bridges;
• Pulp cap, direct or indirect plus filling; 
• Root canals and vital pulpotomies when indicated for the treatment of acute infection or to eliminate pain;
• Apicoectomy performed as a separate procedure, for treatment of acute infection or to eliminate pain, with favorable prognosis;
• Immediate and palliative procedures, including extractions if medically necessary, for relief of pain associated with an oral or maxillofacial condition;
• Tooth reimplantation of accidentally avulsed or displaced anterior tooth, with favorable prognosis;
• Temporary restoration which provides palliative/sedative care (limited to the tooth receiving emergency treatment);
• Initial treatment for acute infection, including, but not limited to, periapical and periodontal infections and abscesses by appropriate methods;
• Preoperative procedures and anesthesia appropriate for optimal patient management; and
• Cast crowns limited to the restoration of root canal treated teeth only.

*Emergency dental services do not require prior authorization. 

  

Dental services that are not covered: 

Covered dental services not subject to the $1,000 emergency dental limit include: 

**These services are covered only after a transplant evaluation determines that the member is a candidate for organ or tissue transplantation.