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Members

Pediatric Dental

The amount you pay for pediatric dental care is regulated by Covered California guidelines. This grid shows your co-insurance and co-payment rates:

Pediatric Dental Services (for Members under Age 19 only)

  • Covered Services are subject to Metal Plan Out of Pocket Maximum

Covered Services

Minimum Coverage (Catastrophic Plan)

Bronze, Silver, Gold & Platinum Plans

Diagnostic and Preventive Care:

  • Oral Exam, Preventive Cleaning, X-ray, Sealants, Fluoride Application Space Maintainers – Fixed

No Charge

No Charge

Basic Services*:

$0 Co-payment after deductible

Please refer to the Pediatric Dental Addendum in the Agreement (EOC)

Major Services:

$0 Co-payment after deductible

Please refer to the Pediatric Dental Addendum in the Agreement (EOC)

Orthodontics*:

  • Orthodontia (Medically Necessary)

$0 Co-payment after deductible

Please refer to the Pediatric Dental Addendum in the Agreement (EOC)

 

Your costs depend on which plan you have.

*Please see your Agreement for more dental benefit information.

Please click here to find dentist that can provide covered dental services.

 

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This information is for Doctors and
Health Care Professionals only.

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