Blue Cross Blue Shield FEP Dental
Class C Major

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 - Limit 1 every 60 months

D2651 Inlay - resin-based composite - two surfaces - Limit 1 every 60 months

D2652 Inlay - resin-based composite - three surfaces - Limit 1 every 60 months

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

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

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

D2710 Crown - resin-based composite (indirect) - Limit 1 every 60 months

D2712 Crown - 3/4 resin-based composite (indirect) - 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 predominantly 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 predominantly 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 predominantly 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 Prefabricated resin crown – Limit 1 per tooth every 60 months for patients up to age 15, including crowns, bridges, prosthetics

D2933 Prefabricated stainless steel crown with 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 up to age 15

D2950 Core buildup, including any pins when required - 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 an 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.
   
• 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.)