Dental Plan

Breakdown of Dental Benefits

Payable Dental Codes

Please submit all claims to:

IPM Trust
1168 E La Cadena Dr.
Riverside, CA 92507
(951) 684-1791

Please note: We are unable to provide Prudent Buyer fee schedules. You will need to contact Blue Cross directly.

• No orthodontic care is covered – including any service relative to orthodontics such as xrays and extractions
• Full-mouth x-rays are payable every 3 years (over the age of 13)
• 4 bite wing and 2 additional are payable every 6 months
• Exams & cleanings are payable every 6 months
• Perio-Maintenance is payable every 6 months in lieu of a prophy
• Full-Mouth Debridement is payable every 2 years
• Root planing/scaling is payable every 2 years
• Prosthetic replacement payable every 5 years(bridges, dentures, partials & crowns)
• Prior extractions are a covered benefit (missing tooth clause)
• Sealants are covered on permanent molars until age 14
  (does not include wisdom teeth)
• Flouride is a covered benefit for adults and children every 6 months
• Composites are covered on all teeth
• Basic general anesthesia is covered w/ no extra minutes
• Nitrous Oxide is not covered
• Nightguards must be pre-authorized
• Implants & cosmetic work are not covered
• Claims over $200 should be pre-authorized
  Especially for Non-PPO Providers
  (claims not pre-authorized are still subject to review & delayed payment)
• X-rays should be submitted with all dental work, except preventative
• Perio charting should be submitted with perio work
• There are no waiting periods