Blue Cross Blue Shield FEP Dental
Class C Major

D0160 Detailed and extensive oral evaluation - problem focused, by report - Limit 2 during the calendar year for any combination of oral evaluations

D2410 Gold Foil – one surface – Limit 1 every 24 months - An alternate benefit will be provided

D2420 Gold Foil – two surfaces – Limit 1 every 24 months - An alternate benefit will be provided

D2430 Gold Foil – three surfaces – Limit 1 every 24 months - An alternate benefit will be provided

D2510 Inlay - metallic - one surface - Limit 1 per tooth every 60 months - An alternate benefit will be provided

D2520 Inlay - metallic - two surfaces -Limit 1 per tooth every 60 months - An alternate benefit will be provided

D2530 Inlay - metallic - three surfaces - Limit 1 per tooth every 60 months - An alternate benefit will be provided

D2542 Onlay - metallic - two surfaces - Limit 1 per tooth every 60 months, including crowns, bridges, prosthetics

D2543 Onlay - metallic - three surfaces - Limit 1 per tooth every 60 months, including crowns, bridges, prosthetics

D2544 Onlay - metallic - four or more surfaces - Limit 1 per tooth every 60 months, including crowns, bridges, prosthetics

D2642 Onlay-porcelain/ceramic - two surfaces - Limit 1 per tooth every 60 months

D2643 Onlay-porcelain/ceramic - three surfaces - Limit 1 per tooth every 60 months

D2644 Onlay porcelain/ceramic - four or more surfaces - Limit 1 per tooth every 60 months

D2650 Inlay - resin-based composite - one surface, lab proc - Limit 1 every 60 months - An alternate benefit will be provided

D2651 Inlay - resin-based composite - two surfaces, lab proc - Limit 1 every 60 months - An alternate benefit will be provided

D2652 Inlay - resin-based composite - three surfaces, lab proc - Limit 1 every 60 months - An alternate benefit will be provided

D2662 Onlay - resin-based composite - two surfaces, lab proc - Limit 1 every 60 months

D2663 Onlay - resin-based composite - three surfaces, lab proc - Limit 1 per tooth every 60 months

D2664 Onlay - resin-based composite - four or more surfaces, lab proc - Limit 1 per tooth every 60 months

D2710 Crown - resin-based composite, lab proc - Limit 1 every 60 months

D2712 Crown 3/4 resin, lab proc - Limit 1 per tooth every 60 months

D2720 Crown resin with high noble metal - Limit 1 per tooth every 60 months

D2721 Crown resin with predominantly base metal - Limit 1 per tooth every 60 months

D2722 Crown resin with noble metal - Limit 1 per tooth every 60 months

D2740 Crown - porcelain/ceramic - Limit 1 per tooth every 60 months, including crowns, bridges, prosthetics

D2750 Crown - porcelain fused to high noble metal - Limit 1 per tooth every 60 months, including crowns, bridges, prosthetics

D2751 Crown - porcelain fused to predominately base metal - Limit 1 per tooth every 60 months, including crowns, bridges, prosthetics

D2752 Crown - porcelain fused to noble metal - Limit 1 per tooth every 60 months, including crowns, bridges, prosthetics

D2753 Crown - porcelain fused to titanium and titanium alloys- Limit 1 per tooth every 60 months, including crowns, bridges, prosthetics

D2780 Crown - 3/4 cast high noble metal - Limit 1 per tooth every 60 months, including crowns, bridges, prosthetics

D2781 Crown - 3/4 cast predominately base metal - Limit 1 per tooth every 60 months, including crowns, bridges, prosthetics

D2782 Crown - 3/4 cast noble metal - Limit 1 per tooth every 60 months, including crowns, bridges, prosthetics

D2783 Crown - 3/4 porcelain/ceramic - Limit 1 per tooth every 60 months, including crowns, bridges, prosthetics. Denied if done on an anterior tooth.

D2790 Crown - full cast high noble metal - Limit 1 per tooth every 60 months, including crowns, bridges, prosthetics

D2791 Crown - full cast predominately base metal - Limit 1 per tooth every 60 months, including crowns, bridges, prosthetics

D2792 Crown - full cast noble metal - Limit 1 per tooth every 60 months, including crowns, bridges, prosthetics

D2794 Crown - titanium and titanium alloys - Limit 1 per tooth every 60 months, including crowns, bridges, prosthetics

D2932 Crown prefabricated resin – Limit 1 per tooth every 60 months for patients up to age 15, including crowns, bridges, prosthetics

D2933 Crown prefabricated stainless steel crown/resin window - Limit 1 per tooth every 60 months for patients up to age of 15 - alternate benefit will be provided

D2934 Prefabricated esthetic coated stainless steel crown, primary tooth – Limit 1 per tooth every 60 months for patients, including crowns, bridges, prosthetics

D2950 Core buildup, including any pins - Limit 1 build up procedure, per tooth every 60 months

D2952 Post and core in addition to crown, indirectly fabricated - Limit 1 buildup procedure, per tooth, every 60 months

D2954 Prefabricated post and core, in addition to crown - Limit 1 buildup procedure, per tooth every 60 months

D2955 Post removal

D2971 Additional procedures to customize a crown to fit under existing partial denture framework - Limit 1 every 60 months

D2980 Crown repair necessitated by restorative material failure – Limit 1 every 12 months

D2981 Inlay Repair necessitated by restorative material failure - Limit 1 every 12 months

D2982 Onlay Repair necessitated by restorative material failure – Limit 1 every 12 months

D2983 Veneer Repair necessitated by restorative material failure – Limit 1 every 12 months

D2990 Resin infiltration of incipient smooth surface lesions

Class C Major Restorative Services Notes:
 

• For reporting and benefit purposes, the completion date for crowns is the cementation date.
   
• An implant is a covered procedure of the plan only if determined to be dentally necessary and the least expensive appropriate treatment.
   
• All major restorative and prosthodontic services (i.e., crown, bridges, implants and dentures) are combined under one replacement limitation under the plan. Benefits for major restorative and prosthodontic services are combined and limited to one every 60 months per tooth or arch depending on the service. For example, if benefits for a removable partial denture are paid, this includes benefits to replace all missing teeth in the arch. No additional benefits for the arch would be considered until the 60 month replacement limit was met.
   
• When dental services that are subject to a frequency limitation were performed prior to your effective date of coverage, the date of the prior service may be counted toward the time, frequency limitations and/or replacement limitations under this dental insurance. (For example, even if a crown, partial bridge, etc. was not placed while covered under BCBS FEP Dental, or paid by BCBS FEP Dental, the frequency limitations may apply.)