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Se requieren espaciadores debido a la pérdida prematura de los dientes para miembros menores de 14 años.

Space maintainers required due to premature loss of teeth for members under age 14.

For each insulin product covered by this health plan, the member's cost share will be a $35 copayment for Tiers 3, 4, and 5 per month supply (unless the total cost of the drug is less than $35.) If an insulin product falls under Tier 1 or Tier 2, refer to the plan's benefits for the appropriate member cost share.

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Metallic and porcelain onlays for members age 16 or older (once each 60 months for each tooth).

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