What the SAIC Dental PPO Plan Covers
The SAIC Dental PPO plan includes only services in the list below.
On This Page:
Preventive Services
The SAIC Dental PPO Plan covers the following preventive services:
- Oral exam (two per participant per calendar year);
- Teeth cleaning (prophylaxis treatment to include scaling and polishing; two per participant per calendar year);
- Topical fluoride (limited to participants ages 18 and under; one per participant per calendar year);
- Bitewing X-rays (two per participant per calendar year);
- Full mouth X-rays (one per participant every 36 consecutive months); and
- Emergency treatment to relieve dental pain when no other definitive dental services are performed (not including X-rays).
Diagnostic Services
The SAIC Dental PPO Plan covers the following diagnostic services:
- Diagnostic X-rays used to diagnose a condition;
- Single X-ray films;
- Additional X-ray films;
- Fissure sealants (limited to participants ages 13 and under; once per participant every three calendar years);
- Simple extractions;
- Surgical extractions (soft tissue impaction, partial bony impaction, complete bony impaction);
- Impactions;
- General anesthesia — only eligible in conjunction with the following:
- Removal of one or more impacted teeth on the same day;
- The extraction of five or more teeth;
- More than one surgical extraction involving more than one quadrant on the same day.
- Amalgam restoration of primary or permanent teeth;
- Composite restoration;
- Root canal therapy — any X-ray, test, lab exam, or follow-up care is part of the allowance for root canal therapy and not a separate dental service;
- Pulp capping;
- Pulpotomy;
- Apicoectomy and retro fill;
- Apicoectomy and retro fill on separate appointment;
- Subgingival curettage;
- Gingivectomy; and
- Space maintainers, fixed unilateral (limited to non-orthodontic treatment).
Restorative Services
The SAIC Dental PPO Plan also provides benefits for the following restorative services:
- Crowns (including, but not limited to, porcelain with gold, cast gold);
- Bridges;
- Stainless steel crowns;
- Recementation:
- Inlay;
- Crown; or
- Bridge;
- Complete upper or lower denture;
- Partial upper or lower denture;
- Denture and partial adjustments;
- Denture reline;
- Denture duplication;
- Denture and partial repairs; and
- Adding teeth or clasps to partial denture.
Orthodontic Services
The SAIC Dental PPO Plan covers the following orthodontic services:
- Xrays and records;
- Initial banding;
- Periodic visits for comprehensive (usually 24 months) treatment for adults and children;
- Interceptive (extension of preventive orthodontics that may localize tooth movement) treatment; and
- Orthodontic retention (removal of appliances, construction and placement of retainer(s)).
Prosthesis Replacement Rule
Certain replacements or additions to existing dentures or bridgework will be covered under the SAIC Dental PPO Plan. However, to be covered by the plan, satisfactory proof must be given that:
- The replacement or addition of teeth is required to replace those that were extracted after the present teeth or bridgework was installed, and the participant must have been covered when the tooth was extracted;
- The present denture or bridgework cannot be made serviceable and must be at least five years old; or
- The present denture is a temporary one and cannot be made permanent, so a permanent denture is needed. The participant must have been covered under this plan when the original tooth was extracted, and replacement must take place within 12 months from the date the temporary one was first installed.
