Benefits For Children 0-20

Your HUSKY Health Dental Plan with the Connecticut Dental Health Partnership offers coverage for the following benefits:

Important to note:

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Care Category
Description
Benefits and Limitations
Diagnostic
Oral examination or screening.
Periodic Exam: 2 times per year

Problem Focused Exam: 4 times per year

Comprehensive Exam: once every 3 years
X-Rays
Complete mouth X-rays, Periapical X-rays, Bitewing X-rays, Occlusal X- rays, Panoramic X-rays.
1. Bitewing X-ray: 1 per year

2. Periapical X-rays: 4 per year

3. Complete Mouth Series or Panoramic X- ray: 1 every 3 years
Preventive
Cleaning, fluoride application.
1 every 6 months per member
Restorative-Fillings
The treatment of tooth decay by the use of silver and/or white fillings.
Fillings are covered once per two years for the same tooth surface.

HUSKY B Copay-20%
Restorative-Crowns
The use of gold, semiprecious, or nonprecious metals and/or porcelain to restore a tooth or teeth which cannot be restored with silver or white restorations.
Covered once per five years. Prior authorization required.

HUSKY B Copay-33%
Endodontics
The treatment of the diseases of the blood vessels and the nerve of the tooth. Endodontic treatment often involves root canal procedures.
Initial and re-treatment root canal procedures covered up to age 21. Prior authorization required.

HUSKY B Copay 20%
Periodontics
The treatment of the supporting tissues of the teeth, gums, and underlying bone, with either surgical or non-surgical procedures (where applicable).
Prior authorization required.
Prosthetics – Removable
The replacement of missing teeth by the use of a removable appliance.
Prior authorization required.

Husky B Copay 50%
Prosthetics –

Adjustments & Relines
The repair or modification of existing dentures so that they can continue to be serviceable.
Is allowed after 6 months after the initial placement of the denture(s).

HUSKY B Copay 20%
Prosthetics – Fixed
The use of gold, semiprecious, or precious metal to replace a missing tooth or teeth. Fixed prosthetics may include bridgework, implants and implant retained crowns and dentures.
Not covered but may be covered in special circumstances with medical necessity
Extractions
The extraction, either simple or surgical, of either a single tooth or multiple teeth.
Covered for all permanent, baby and extra teeth. Biopsies, bone grafting, alveoloplasty, facial surgery for trauma and inherited facial conditions. Prior authorization is required.

Husky B Copay 20% simple extraction or 33% surgical.
Wisdom Tooth Removal and Impactions
The surgical removal of fully erupted teeth when medically necessary or teeth partially or fully covered by gum tissue or bone.
Prior authorization required.

HUSKY B Copay 33%
Oral Surgery
The shaping of bone ridges, the treatment of an abscess, biopsies of soft and hard tissues, reconstructive surgeries etc.
Requires prior authorization.

HUSKY B Copay 33%
Orthodontics
The straightening of teeth for significant dental health reasons.
Covered once per member per lifetime

HUSKY A, HUSKY C, HUSKY
Prior Authorization required

HUSKY B
Limited to recipients under age 19
No Prior Authorization required. Benefit – $725.00

Member is responsible for balance up to $3,198.21
Athletic Mouth Guard
Mouthguards are worn over the top row of teeth during sports to help prevent an oral injury. They protect against broken teeth, cut lips, and other damage to the mouth.
Initial and re-treatment root canal procedures covered up to age 21. Prior authorization required.

HUSKY B Copay 20%
Occlusal “Night” Guards
A removable acrylic appliance intended to relieve temporomandibular joint pain and other effects of grinding the teeth (bruxism). Usually worn at night to prevent grinding during sleep.
Prior Authorization required for members with severe clenching or tooth grinding habits. May be used to treat temporomandibular joint (TMJ) problems.

HUSKY B Copay-20%
Deep Sedation/General Anesthesia
Covered for general dental procedures and tooth extractions in children under the age of 9 OR for children under the age of 21 with behavioral related conditions such as autism, cerebral palsy, intellectual delays.
Prior Authorization required.
Inhalation Sedation
Nitrous oxide. Covered for adults over the age of 21 with behavioral related conditions such as autism, cerebral palsy, intellectual delays and have a diagnosis of 318.0 or greater.
Prior Authorization required.