Department of Civil Service

This dental plan provides benefits for most types of dental services. Your level of dental benefits is known as the EmblemHealth Preferred Dental Plan. This document is your Certificate of Insurance.

Preferred Dental Plan Non-Participating Provider Reimbursement Schedule as of January 1, 2016.

The following is a selective listing of EmblemHealth's maximum reimbursements for common dental procedures rendered by non-participating dentists. As EmblemHealth's participating dentists accept EmblemHealth's payment as payment-in-full for covered services rendered, your personal out-of-pocket expenses, if any, are minimal and your benefits are maximized. All covered services rendered by participating and non-participating dentists are paid based on EmblemHealth's Preferred Dental Schedule of Allowances.

The listing of the most common dental procedures shown below indicates the amount that EmblemHealth will reimburse for covered services rendered by non-participating providers. Your per person calendar year benefit maximum for covered participating and non-participating services is $2,300 including orthodontia. Orthodontic services obtained during a calendar year are subject to both the calendar year maximum and the lifetime orthodontia maximum of $2,300. Specific services that are not covered are listed under Dental Exclusions. Those services that have limitations are noted as such in the Covered Services and Limitations section of this certificate.

Covered to the end of month, age 14, on the first and second permanent molars and bicuspids once every three years.

In certain circumstances, when a palliative treatment and another procedure are performed during the same visit, the allowance for the palliative treatment will be included in the allowance of the other procedure.

EmblemHealth will cover fourteen (14) standard periapical x-ray films or one (1) panoramic film once every three (3) years. EmblemHealth will also cover two (2) occlusal intra-oral x-ray films in a three (3) year period. Individual periapical x-rays performed on the same day as a full mouth series are not covered. Duplication of x-rays is not covered.

Each dependent is covered for one mouth guard per lifetime. It must be prescribed by a dentist and used for athletic purposes.

Composite fillings on molars are reimbursed at the amalgam fee for the number of surfaces reported.

The Schedule of Allowances imposes a maximum benefit for fillings done on the same tooth by the same Dentist or Provider within a six (6) month, period. EmblemHealth will not pay more than this maximum benefit for fillings for each Member in any six (6) month period.

If two (2) fillings are done on the same posterior tooth on the same day, EmblemHealth's allowance will be up to the Scheduled amount for a three (3) surface amalgam.

If two (2) fillings are done on the same anterior tooth on the same day, EmblemHealth's allowance will be up to the Scheduled amount for three (3) surface composite filling.

Repeated periodontal surgeries or grafts will not be covered for a period of three (3) years from the date of the original surgery or graft.

Pulpotomy is covered once per tooth, per lifetime. However, pulpotomy is not covered if root canal therapy was done on the tooth by the same Dentist or Provider within the prior three (3) month period.

If any combination of apicoectomy, root end amalgam and apical curettage is done on the same tooth by the same Dentist or Provider within a three (3) month period of root canal therapy, EmblemHealth will not apply the Scheduled amounts for these services. EmblemHealth will apply a combined allowance for these services.

Occlusal adjustments done on the same tooth and in conjunction with fillings, prosthetic services, root canal therapy or repairs, inlays and crowns are not covered.

The allowance for incision and drainage done within two (2) weeks of root canal therapy or periodontal surgery on the same tooth by the same Dentist or Provider will be deducted from the allowance for the root canal therapy or periodontal surgery.

Pulp capping is not covered.

Surgical replacement of rubber dam, recalcification of perforation, preparation of canal for post or dowels, and bleaching of discolored teeth are not covered.

If the repair of a partial denture is done in conjunction with the insertion of a new denture in the same area of the mouth, EmblemHealth's allowance will be the Scheduled amount for the insertion of the new denture.

If a denture adjustment is performed in conjunction with palliative treatment, EmblemHealth's allowance will be the Scheduled amount for the palliative treatment.

If the repair of a broken denture is performed in the same arch as the insertion of a full denture, EmblemHealth's allowance will be the Scheduled amount for the insertion of the new denture.

The allowance for an upper and lower overdenture will be the Scheduled amount to the upper and and lower dentures. There will be no benefits for any treatment of the abutment tooth or attachment tooth.

You are not covered for the replacement or the substitution of appliances unless five (5) years have passed since the appliance was inserted.

If a fixed bridge and partial denture are inserted in the same arch, only the partial denture is covered during the prosthetic replacement limitation period of five (5) years.

You are not covered for implants.

You are not covered for double or multiple abutments.

Crowns or pontics for attachment or clasp purposes are not covered unless the tooth is so broken down that it cannot be restored by fillings. A cantilever pontic used for attachment purposes is not covered.

Splints are not covered except when a missing tooth is being replaced. Only the portion replacing the missing tooth is covered.

Crowns used in splints for periodontal conditions are not covered.

Crown buildups done in connection with individual crowns and abutments are not covered.

Crowns and inlays used as abutments are not covered unless they are used as primary support for fixed appliances.

Precious metal material used in crowns is reimbursed at a base metal rate.

Duplication, rebase or chairside reline to a denture is limited to one (1) per denture in a five year period. This applies to both full and partial dentures.

Acrylic crowns are only covered on the six (6) anterior teeth. They must be laboratory processed and permanent. The allowance for acrylic crowns will be the Scheduled amount for single crowns, not the Scheduled amount for a bridge abutment or splint.

Rebase or repair of new dentures are not covered until six (6) months after insertion.

Adjustment of appliances is not covered within one (1) year of insertion.

EmblemHealth does not cover services or appliances used solely as an adjunct to periodontal care.

Precision attachment, metal coping, tissue conditioning and stress breakers are not covered.

Cosmetic surgery and/or treatment is not covered unless medically necessary.

There is not a separate allowance for a temporary service or appliance. The allowance for a temporary service or appliance is included in the allowance for the completed, permanent service or appliance.

General anesthesia must be rendered in connection with a covered service. IV sedation is covered when administered according to the American Dental Association guidelines.

Adjustment of appliance is not covered within one year of insertion. Precision attachment, metal coping, tissue conditioning, and stress breakers are not covered.

The allowance for an upper or lower overdenture will be the Scheduled amount for full upper and lower dentures. There will be no benefits for any treatment of the abutment tooth or attachment tooth.

You are not covered for the replacement or substitution of appliances unless five (5) years have passed since the appliance was inserted.

If a fixed bridge and partial denture are inserted in the same arch, only the partial denture is covered during the prosthetic replacement limitation period of five (5) years.

Duplication, rebase or chairside reline to a denture is limited to one per-denture in a five year period. This applies to both full and partial dentures.

If a three surface inlay, crown or abutment is done on a tooth that has been filled within the last 6 months, EmblemHealth will deduct the schedule amount for the filling from its payment for the inlay, crown or abutment.

Crown buildups done in connection with individual crowns and abutments are not covered.

Each abutment and each pontic in a fixed bridge constitutes a unit in a bridge. You are not covered for implants.

Crowns or pontics for attachments or clasp purposes are not covered unless the tooth is so broken down that it cannot be restored by fillings. A cantilever pontic used for attachment purposes is not covered.

There is not a separate allowance for a temporary service or appliance. The allowance for a temporary service or appliance is included in the allowance for a completed, permanent service or appliance. Precious metal material used in crown is reimbursed at a base metal rate. Crowns used as splints for periodontal conditions are not covered. Acrylic crowns are only covered on the six (6) anterior teeth. They must be laboratory processed and permanent. The allowance for acrylic crowns will be the Scheduled amount for single crowns, not the Scheduled amount for a bridge abutment or splint.

The charge for cementation of a crown/inlay is included in the allowance for the crown/inlay.

Posts are only covered if there is evidence of root canal therapy on the tooth. Pins are covered once every six (6) months. However, pins are not covered if they are inserted in conjunction with a prosthetic service. Core build-ups including pins are not covered.

The allowance for chairside laminates for anterior teeth will be the comparable maximum composite Scheduled amount.

Crowns and inlays used as abutments are not covered unless they are used as primary support for fixed appliances. The allowance for a one surface inlay will be the schedule amount for a one surface amalgam.

The allowance for an onlay will be the schedule amount for a three surface inlay. If an onlay and three surface inlays are done on the same tooth on the same day, EmblemHealth's allowance will be the schedule amount for the three surface inlay. A separate allowance for the onlay will not be provided.

An allowance for composite resin inlays will be the schedule amount for the amalgam restoration.

Examination, study models, x-rays, diagnosis, construction and insertion of orthodontic appliances, including all previous proplylactic appliances, for tooth guidance, including multi-phasal orthodintia. Multi-Phasal Orthodontia services are included in your benefit under the administration of insertion of appliance up to a lifetime maximum of $550.

Your dentist should submit your regular initial appliance and workup fee as a separate charge with the code indicated.

*Pre-determinations for all dental services exceeding $300 may be required.

**Requires Pre-determination