FDA-approved opioid agonist and antagonist treatment medications and the dispensing and administration of such medications (member cost share does not apply).
Routine dental care. This includes: one initial oral exam; one periodic oral exam twice per calendar year; one cleaning (prophylaxis only - does not include periodontal cleaning) twice per calendar year; and one set of bitewings twice per calendar year. Dental services also include emergency oral exams, when needed.
(The member's cost share is waived when labs and tests are performed in the member's home or mobile unit and the amount the member pays for MRI, CT scan, positron emission tomography and nuclear cardiology is waived for the provider's interpretation costs when these tests are furnished during a covered day surgery admission or an emergency room visit.)