MPE Preferred Provider (CLOSED) PLAN

Please be advised that procedure codes are subject to change during the plan year.

Charges for co-paid services received after your annual maximum has been reached are not covered.

Paid-In-Full Services
These dental services require no patient co-pay and are excluded from the annual plan maximum:

Diagnostic and Preventive
Comprehensive oral evaluation, for new or established patient, once every 5 years per provider
Periodic oral evaluation, once every 6 consecutive months*
Limited oral evaluation (no separate benefit paid for some definitive treatment if performed on the same day), three occurrences in 6 months
Oral evaluation for a patient under 3 years of age and counseling
with primary caregiver
Intraoral X-rays, complete series or panorex, once every 60 months
Intraoral periapical X-ray
Bitewing X-rays, once every 6 consecutive months for
dependents age 18 and under; once every 12 consecutive
months for adults*
Pulp vitality tests
Adult and child prophylaxis (cleaning), once every 6 consecutive
months*
Fluoride treatment, once every 6 consecutive months for
dependents age 18 and under*
Topical fluoride varnish, therapeutic application, for moderate to
high caries risk patients
Prescription strength fluoride toothpaste dispensed in the dental
office available for adult patients following certain periodontal
surgeries
Sealant per tooth, only on unrestored permanent molars, once
every 48 months for dependents age 18 and under
Chlorhexidine anti-bacterial mouthrinse dispensed in the dental
office for patients receiving periodontal scaling and root
planing, once every 6 months
Space maintainers, once per lifetime, for dependents age 14 and
under
Re-cementation of space maintainers
Removal of fixed space maintainer

*For example, if you have an examination and cleaning on July 15, 2008
you may not have another covered examination or cleaning until January 15, 2009.