Covered dental services

Please see the below chart for what you will pay and covered services.

Preventive Dental Benefits

EmblemHealth VIP Dual Reserve (HMO D-SNP) and EmblemHealth VIP Dual (HMO-D-SNP)

You Pay:

Other EmblemHealth plans

You Pay:
Routine Cleaning/1 every 6 months $0 $0
Fluoride application; Fluoride treatment/1 every 6 months $0 $0
Single Tooth x-rays; Bitewing x-rays/1 every 6 months $0 $0
Periodic Oral Exam; Limited Oral Exam/1 every 6 months $0 $0
*Comprehensive Dental Benefits    
Fillings/1 every 24 months $0 $0
Recement Crown (covered after 6 months) $0 $0
Prefabricated Stainless Steel Crowns/1 every 60 months $0 $0
Post and Core in Addition to Crown/ 1 every 60 months $0 $0
Inlay/Onlay and Single Crown Restoration/1 every 60 months $0 $125
Endodontic/Periodontic/Extractions    
Therapeutic Pulpotomy/1 per lifetime $0 $0
Root Canal (molar) Once per permanent tooth per lifetime $0 $20
Root Canal (except molar)/1 per lifetime $0 $0
Gingivectomy/Gingivoplasty per Quadrant/1 every 36 months $0 $20
Osseous surgery – (1-3 teeth) per Quadrant/1 every 60 months $0 $75
Osseous surgery – (4 or more teeth) per Quadrant/1 every 60 months $0 $150
Periodontal Maintenance/1 every 36 months $0 $0
Apicoectomy/Periradicular Services/ 1 per lifetime $0 $20
Scaling and Root Planing/Once every 36 months per quadrant $0 $0
Prosthodontics, Oral/Maxillofacial    
Complete or Partial Denture/1 every 60 months $0 $150
Complete Denture Repair/1 every 12 months $0 $0
Complete Denture Rebase and Reline/1 every 36 months $0 $0
Fixed Partial Denture Pontics, Retainers, Recement/1 every 60 months $0 $150
Extraction or Removal of Tooth – Soft Tissue/1 per lifetime $0 $0
Removal of Bony Impacted Tooth/1 per lifetime $0 $50
Other Surgical Procedures/1 per lifetime $0 $50
Alveoloplasty without Extraction – per Quadrant/1 every 12 months $0 $0
Excision, Incision and Other Repair Procedures $0 $50
Vestibuloplasty – 1 arch per lifetime $0 $50