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Care Improvement Plus Dental Benefits
  BASIC BENEFIT (CIP GOLD AND PLATINUM MEMBERS ONLY):
 
CDT 7 ADA Service Descriptions Basic
In-Network		 Limitations
  Per Office Visit Co-pay $10  
D0120 PERIODIC ORAL EVAL Covered in Full 1 per yr either D0120 or D0150
(1 every 3 yrs)
D0150 COMP ORAL EVAL Covered in Full
D0272 BITEWINGS-2 FILMS Covered in Full 1 per year either
D0272 or D0274
D0274 BITEWINGS-4 FILMS Covered in Full
D1110 PROPHYLAXIS-ADULT Covered in Full 1 per year
D5410 ADJUST COMPLT DENTURE-MAXIL Covered in Full 2 per year of
any of the 4
D5410 - D5422
D5411 ADJUST COMPLT DENTURE-MANDIB Covered in Full
D5421 ADJUST PART DENTURE-MAXIL Covered in Full
D5422 ADJUST PART DENTURE-MANDIB Covered in Full

PLEASE NOTE: MEMBERS HAVE A $10 OFFICE VISIT CO-PAY

ENHANCED BENEFIT (SILVER MEMBERS ONLY):

CDT 7 ADA Service Descriptions Basic
In-Network		 Limitations
  Per Office Visit Co-pay $15  
D0120 PERIODIC ORAL EVAL Covered in Full 1 per yr either D0120 or D0150
(1 every 3 yrs)
D0150 COMP ORAL EVAL Covered in Full
D0220 INTRAORAL-PERIAPICAL FIRST FILM Covered in Full 1 per yr
D0230 INTRAORAL-PERIAPICAL EA ADD FILM Covered in Full 4 per yr
D0272 BITEWINGS-2 FILMS Covered in Full 1 per year either
D0272 or D0274
D0274 BITEWINGS-4 FILMS Covered in Full
D1110 PROPHYLAXIS-ADULT Covered in Full 1 per year
D5410 ADJUST COMPLT DENTURE-MAXIL Covered in Full 2 per year of
any of the 4
D5410 - D5422
D5411 ADJUST COMPLT DENTURE-MANDIB Covered in Full
D5421 ADJUST PART DENTURE-MAXIL Covered in Full
D5422 ADJUST PART DENTURE-MANDIB Covered in Full
D2140 AMALGAM-1 SURFACE PERM Covered in Full up to a total of
4 restorations
per year
not to exceed
6 total surfaces
D2150 AMALGAM-2 SURFACES PERM Covered in Full
D2160 AMALGAM-3 SURFACES PERM Covered in Full
D2161 AMALGAM-4/MORE SURFACES PERM Covered in Full
D2330 RESIN-BASED COMPOSITE-1 SURFACE ANT Covered in Full
D2331 RESIN-BASED COMPOSITE-2 SURFACES ANT Covered in Full
D2332 RESIN-BASED COMPOSITE-3 SURFACES ANT Covered in Full
D2335 RESIN-BASED COMPOSITE-4/MORE SURF-INCISAL ANGLE Covered in Full
D2391 RESIN-BASED COMPOSITE - 1 SURFACE, POSTERIOR Covered in Full
D2392 RESIN-BASED COMPOSITE - 2 SURFACES, POSTERIOR Covered in Full
D2393 RESIN-BASED COMPOSITE - 3 SURFACES, POSTERIOR Covered in Full
D2394 RESIN-BASED COMPOSITE - 4 OR MORE SURFACES, POSTERIOR Covered in Full
D4341 PERIODONTAL SCALING & ROOT PLANING PER QUADRANT Covered in Full 2 quadrants of
Scaling per year either D4341 or D4342
D4342 PERIODONTAL SCALING AND ROOT PLANING - 1-3 TEETH, PER QD Covered in Full

PLEASE NOTE: MEMBERS HAVE A $15 OFFICE VISIT CO-PAY

Members may access additional services at a discounted rate when services are rendered by a Participating Provider.

 

 
   
       
 
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