Pediatric Dental

Pediatric Dental

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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 information
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 a dentist that can provide covered dental services.

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