Citi Benefits Handbook

Routine oral exams: maximum of two exams per calendar year (additional medically necessary oral exams will be reviewed by MetLife Dental Consultants);
Routine cleanings: maximum of two cleanings per calendar year or a maximum of three cleanings per calendar year for employees enrolled in a Healthy Pregnancy Program through Anthem or Aetna, Citi's Diabetes Management Program or Citi's Disease Management Program. Note: members eligible to receive a third cleaning are required to submit a Preventative Plus Form completed by their provider with the claim to receive reimbursement. This form is available online at www.citibenefits.com or by calling MetLife at 1 (888) 830-7380.
Fluoride treatments to age 15: maximum of two applications per calendar year;
Space maintainers to age 19;
Full mouth series and panoramic X-rays: once every 60 months;
Bitewing X-rays: up to one set per calendar year for adults and two sets per calendar year for children;
Sealants: on the 1st and 2nd permanent molars only, to age 19; one application per tooth every 60 months; and
Palliative treatments: emergency treatment only; not paid as a separate benefit from other services on the same day.

Fillings (except gold fillings): includes amalgam (silver) and composite (white) fillings to restore injured or decayed teeth;
Extractions;
Endodontic treatment;
Oral surgery, unless covered under your medical plan or your HMO;
Periodontal surgery: once every 36 months per quad;
Repair prosthetics: no limit;
Recementing (crowns, inlays, onlays, bridgework or dentures): no limit;
Addition of teeth to existing partial or full denture, or addition of teeth to existing fixed bridgework; bridgework must be at least five years old and unserviceable); limited to once every five years;
Denture relining and rebasing: once every 36 months if 6 months after initial installation of the denture;
Adjustments to removable dentures made within the first six months of installation;
Periodontal maintenance treatments, up to four per calendar year; this covers up to two regular cleanings per year paid at 100% and up to four periodontal maintenance visits per year paid at 80%; these services are combined and do not exceed four total per year;
Periodontal scaling and root planing: once every 24 months (subject to consultant review);
Bruxism appliances; and
General anesthesia: when medically necessary, as determined by the Claims Administrator, and administered in connection with a covered service.

Inlays, onlays and crowns (including precision attachments for dentures; must be at least five years old and unserviceable): limited to one per tooth every five years;
Removable dentures: initial installation;
Removable dentures (replacement of an existing removable denture or fixed bridgework with new denture; dentures must be at least five years old and unserviceable): limited to once every five years;
Fixed bridgework, including inlays, onlays and crowns used to secure a bridge: initial installation;
Fixed bridgework, including inlays, onlays and crowns used to secure a bridge (replacement of an existing removable denture or fixed bridgework with new fixed bridgework; bridgework must be at least five years old and unserviceable): limited to once every five years; and
Dental implants (subject to medical necessity and consultant review): medical necessity, as determined by the Claims Administrator, is based on the number and distribution of all missing, unreplaced teeth in the arch, as well as the overall periodontal condition of the remaining normal teeth.

Orthodontic X-rays;
Evaluation;
Treatment plan and record;
Services or supplies to prevent, diagnose or correct a misalignment of the teeth, bite, jaws or jaw-joint relationship;
Removable and/or fixed appliance(s) insertion for interceptive treatment;
Temporomandibular joint (TMJ) disorder appliances (for TMJ dysfunction that does not result from an accident); and
Harmful habit appliances: includes fixed or removable appliances.