Oral Health Care Services

Dental services provided to eligible persons include:

• Routine dental exams, prophylaxis and dental cleanings
• X-rays
• Fillings
• Replacements
• Treatment of gum disease
• Oral surgery
• Dental Implants (limited services; restrictions apply; medical necessity only)

Only dental procedures included in the most current Oral Health Care Formulary can be performed under this service category.

• Oral Health Care Formulary - summary letter (07/05/23)
• Summary of  Available Dental Care Procedures (03/01/23)
• Letter of Medical Necessity - Dental Implant Codes (03/01/23)
• Letter of Medical Necessity - Dental Implant Codes - fillable (03/01/23)
• Tobacco Cessation Counseling Protocol
• Oral Health Care Formulary Review Request Form (Revised 07/20/20)