Will dental insurance pay for antibiotics?

Does dental insurance cover prescriptions? No, dental insurance will not cover antibiotics, even when needed after dental work. Antibiotics are prescription drugs generally covered by medical insurance or a prescription drug plan.

Any infection requiring antibiotics is a medical issue, not a dental issue; therefore, your health insurance covers it. Health insurance can also cover other dental procedures, including oral infections, dental implants, and tooth biopsies if they are medically necessary. However, there are limitations to what each policy will cover. 

Keep reading to learn what dental insurance covers and why your dental policy won’t pay for antibiotics. We’ll discuss when you might need antibiotics after the dentist and how you can bill your medical insurance for dental work.

Does dental insurance cover antibiotics?

The short answer is no. Your dental insurance will not cover antibiotics, even if you need them after dental surgery. However, this doesn’t mean you’re responsible for paying for your prescriptions out of pocket.

Does medical insurance cover dental prescriptions? Yes, health insurance or your prescription drug plan will cover any antibiotics you need due to dental work based on your policy’s terms.

When would you need antibiotics for dental work? Dentists usually prescribe antibiotics when dental work damages the soft tissue in your mouth. For example, root canals and extractions are the most common procedures that can damage soft tissue and increase the risk of infection.

Your dentist will likely prescribe an antibiotic after one of these procedures. Some dentists only prescribe antibiotics when an infection begins, while others will recommend antibiotics as a precautionary measure. If the antibiotics are preventive, you can decide to fill the prescription or not.

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How to Bill Medical Insurance for Dental Antibiotics

When you bring your dental prescription to the pharmacy, your pharmacist will automatically process the prescription through your medical insurance on file. Review your health insurance policy before your dental appointment to know which medications are covered.

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What does dental insurance cover?

Although it won’t cover antibiotics, dental insurance provides coverage for:

• Routine maintenance, including teeth cleanings and exams
• Basic dental procedures, including fillings, root canals, and removals
• Major dental procedures, including crowns and bridges

Some dental insurance policies may also cover dentures or other dental implants, but you’ll likely have to use a health insurance policy. (For more information, read our “Will Medicare pay for dental implants?“).

Is dental insurance considered health insurance? No, it isn’t. Unlike health insurance — which covers emergencies and unexpected illnesses or injuries — dental insurance is for preventative care.

For example, dental policies cover the basic maintenance of your teeth and share costs with customers for more expensive preventative procedures. The standard structure of dental policies follows the 100-80-50 coverage model:

• Covers 100% of cleanings and exams
• Covers 80% of basic procedures
• Covers 50% of major procedures

This insurance model assumes customers will keep up with annual cleanings, exams, and reduce the likelihood of more serious dental work in the future. While dental insurance is relatively cheap, this means that you’re often paying a lot out of pocket for certain dental procedures.

Can health insurance cover dental work?

Yes, your health insurance policy will cover antibiotics and certain dental procedures. 

Which dental prescriptions does your health insurance plan cover? That depends on your policy. 

Read the summary of benefits and coverage section of your health insurance policy to see which brands of antibiotics it covers, or call your insurer directly for a summary of benefits.

What dental procedures does medical insurance cover? You can use health insurance for certain types of dental work, including x-rays, bone grafts, wisdom teeth removal, and emergency trauma procedures for damaged teeth. (For more information, read our “Will health insurance pay for wisdom teeth removal surgery?“).

What do dental insurance plans exclude?

Dental insurance won’t cover pre-existing conditions. You’re also unlikely to have orthodontic or cosmetic procedures coverage unless you require it due to an accident or emergency.

Dental plans typically exclude:

• Replacement or duplicate dentures
• Replacement crowns and bridges
• Occupational injuries covered by worker’s compensation
• Space maintainers for children under 15
• General anesthesia

Your policy may also exclude certain crown and sealant types. For example, your dental policy may cover the total cost of ceramic crowns but only the partial cost of metal or porcelain crowns. Look at your dental policy and discuss different options with your dentist before deciding on a dental procedure.

How much does dental insurance cost?

Your dental insurance rates depend on your type of dental insurance plan. There are three kinds of dental policies to choose from:

• Dental health maintenance organization (DHMO)
• Preferred provider organization (PPO)
• Fee-for-service (indemnity) plans

DHMO insurance plans provide you with a list of dentists and insurance rates, but you can only choose a dental office from the insurer’s approved list. However, you can pay extra to see whatever dentist you like with a PPO dental plan. 

Dental indemnity plans are more expensive. These plans offer a fee-for-service model where you pay a percentage of the procedure, and the insurance company pays the rest. The percentage you pay varies based on procedure type.

However, many dental offices are starting to provide fee-for-service programs to give customers a chance to find affordable dental care without an insurance policy. Shop for multiple insurers and speak with local dentists to see which offers you the most affordable coverage.

BQ: You will pay anywhere from $15 to $50 per month — or $360 per year — for dental insurance, depending on your policy type.

Even with dental insurance, you will still incur more costs than just your monthly payment. Listed below are other costs associated with dental work.

• Copays. You must pay a copay at each dental appointment. Some dental plans have $0 copays, but you typically pay between $15 – $20 per visit.

• Deductibles. A deductible is an amount you pay before insurance kicks in to cover the remaining cost. You must pay the deductible before your dental insurance pays for any procedure.

• Coinsurance. After you meet your deductible, some dental plans still require payment of a percentage of the procedure. Coinsurance is usually an 80/20 or 70/30 plan.
• Annual maximums. An annual maximum is the amount your dental insurance covers per year. You’re responsible for additional costs once you exceed your policy maximum.

Because of these additional costs, it’s important to shop for multiple dental insurers in your area to find the best coverage. You can find the best dental insurance rates when comparing quotes from at least three different insurance companies. 

Read more: What is the best type of dental insurance plan: HMO, PPO or indemnity?

Dental Insurance Coverage for Antibiotics: What You Need to Know

Dental insurance doesn’t cover antibiotics, but your health insurance policy will. Your local pharmacy will bill your medical insurance or prescription drug plan if your dentist prescribes you an antibiotic. You can also use health insurance to cover other dental procedures, including emergency oral trauma surgeries, X-rays, and more. 

Unlike health insurance, dental plans provide preventative care coverage. Dental policies typically include a 100/80/50 coverage model, covering all of your routine maintenance procedures. However, the insurance company only provides partial coverage for basic and major dental work.

You’ll have to pay out of pocket for dental work not covered by your insurance policy, including any cosmetic or orthodontic procedures you need. You may also be required to pay a copay or coinsurance on top of your monthly dental insurance rates.

To find affordable dental insurance, compare insurance quotes from at least three different companies in your state and consider policy maximums. After you reach your annual maximum, you’ll have to pay for dental work until your renewal date. Shop for the top dental insurance coverage plan now so you aren’t paying more in the future.

Start using the online dental insurance quotes tool today by entering your zip code now!

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Case Studies: Dental Insurance Coverage for Antibiotics

Case Study 1: The Comprehensive Dental Plan

Sarah, a policyholder with a comprehensive dental insurance plan, required a course of antibiotics to address a severe dental infection. As per her plan’s coverage, antibiotics prescribed by a dentist were fully covered. Sarah submitted the necessary documentation, including the prescription, to her insurance provider, and the claim was processed without any issues.

Case Study 2: The Limited Coverage Plan

John, covered under a dental insurance plan with limited coverage, visited his dentist for a tooth extraction that later developed an infection. Although the antibiotics prescribed by the dentist were essential for his recovery, John’s plan only provided partial coverage for prescription medications. He was responsible for a portion of the antibiotic costs, which he paid out of pocket.

Case Study 3: The Exclusion Clause

Emily had dental insurance through her employer, but her plan had an exclusion clause that specifically stated antibiotics were not covered. When Emily needed antibiotics to treat an oral infection, she was informed by her insurance provider that the cost of the medication would not be reimbursed. Emily had to bear the full expense of the antibiotics on her own.

Case Study 4: Prior Authorization Requirement

Michael had a dental insurance plan that required prior authorization for certain medications, including antibiotics. When he needed antibiotics for a dental procedure, his dentist submitted the necessary information to the insurance company for approval. Fortunately, the prior authorization process was successful, and Michael’s insurance plan covered the prescribed antibiotics.

Case Study 5: In-Network vs. Out-of-Network Dentist

Lisa had dental insurance through a PPO plan that provided coverage for both in-network and out-of-network providers. However, the plan had varying coverage levels depending on the dentist chosen. When Lisa visited an out-of-network dentist and needed antibiotics, she found that her plan covered a lower percentage of the medication costs compared to an in-network dentist.

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