| This is an overview of coverage. Please refer to the Universal Exclusions and Limitations reference sheet for additional plan provisions. A comprehensive description of coverage, benefits and limitations is contained in the Combined Evidence of Coverage and Disclosure Form. |
| |
PREVENTIVE and DIAGNOSTIC CARE:
COVERAGE BEGINS UPON APPROVAL OF YOUR APPLICATION. |
| |
| Comprehensive oral evaluation |
Participating
| 100% |
Non-Participating
| $16 |
Periodic oral exam
(limited to two per member per year) |
Participating
| 100% |
Non-Participating
| $16 |
| Initial oral evaluationproblem focused |
Participating
| 100% |
Non-Participating
| $16 |
| Bitewing X-rays single film |
Participating
| 100% |
Non-Participating
| $12 |
| Bitewing X-rays two films |
Participating
| 100% |
Non-Participating
| $15 |
| Single (periapical) X-rays first film |
Participating
| 100% |
Non-Participating
| $9 |
| Single X-rays additional films |
Participating
| 100% |
Non-Participating
| $9 |
| Bitewing X-rays four films |
Participating
| 100% |
Non-Participating
| $21 |
Full mouth X-rays
(limited to one set every 3 years) |
Participating
| 100% |
Non-Participating
| $45 |
| Available for groups with 10 or more eligible employees enrolled in Blue Cross Medical Coverage, a minimum of 25% participation by eligible employees and employee and dependent premiums collected through payroll deduction. |
| |
Routine cleaning adult
(limited to two per year per adult per year) |
Participating
| 100% |
Non-Participating
| $35 |
Routine cleaning child
(limited to two per child per year) |
Participating
| 100% |
Non-Participating
| $22 |
Cleaning with fluoride
(limited to two per child per year) |
Participating
| 100% |
Non-Participating
| $35 |
Topical fluoride only
(limited to two per child per year) |
Participating
| 100% |
Non-Participating
| $15 |
| |
| |
BASIC DENTAL CARE:
COVERAGE BEGINS AFTER THE POLICY HAS BEEN IN EFFECT FOR SIX CONTINUOUS MONTHS. |
| |
| Filling one surface, primary |
Participating
| $26 |
Non-Participating
| $26 |
| Filling one surface, permanent |
Participating
| $28 |
Non-Participating
| $28 |
| Filling two surfaces, primary |
Participating
| $34 |
Non-Participating
| $34 |
| Filling two surfaces, permanent |
Participating
| $37 |
Non-Participating
| $37 |
| Filling three surfaces, primary |
Participating
| $40 |
Non-Participating
| $40 |
| If
a combined total of 10 or more employees enroll in the Small Group
Voluntary PPO Dental Plan and/or the Dental Saver Select HMO Plan,
child orthodontic benefits (up to $500 lifetime maximum per child)
will be added to the Voluntary PPO Dental Plan at no additional
cost. |
| |
| Filling three surfaces, permanent |
Participating
| $42 |
Non-Participating
| $42 |
| Filling four or more surfaces, primary |
Participating
| $47 |
Non-Participating
| $47 |
| Filling four or more surfaces, permanent |
Participating
| $50 |
Non-Participating
| $50 |
| Extraction single tooth (simple) |
Participating
| $32 |
Non-Participating
| $32 |
| Extraction each additional tooth (simple) |
Participating
| $32 |
Non-Participating
| $32 |
| Surgical extraction |
Participating
| $60 |
Non-Participating
| $60 |
| Removal of impacted tooth soft tissue/partial bony/complete bony |
Participating
| $80/$95/$120 |
Non-Participating
| $80/$95/$120 |
| |
| |
MAJOR DENTAL CARE:
COVERAGE BEGINS AFTER THE POLICY HAS BEEN IN EFFECT FOR 12 CONTINUOUS MONTHS. |
| |
| Scaling/root
planning per quadrant |
Participating
| $36 |
Non-Participating
| $36 |
| Gingivectomy per tooth/per quadrant |
Participating
| $32/$115 |
Non-Participating
| $32/$115 |
| AMOUNTS LISTED ARE WHAT THE PLAN PAYS. The plan pays either the specified amount, or the actual amount charged by your dentist, whichever is lower. You pay any charges in excess of the stated benefit. |
| |
| Root canal one canal |
Participating
| $120 |
Non-Participating
| $120 |
| Root canal two canals |
Participating
| $145 |
Non-Participating
| $145 |
| Root canal three canals |
Participating
| $185 |
Non-Participating
| $185 |
| Crown (except stainless steel) |
Participating
| $200 |
Non-Participating
| $200 |
| Stainless steel crown |
Participating
| $50 |
Non-Participating
| $50 |
| Pontic |
Participating
| $200 |
Non-Participating
| $200 |
| Complete denture (upper or lower) |
Participating
| $260 |
Non-Participating
| $260 |
| Partial denture (upper or lower) |
Participating
| $240 |
Non-Participating
| $240 |
| Denture
reline (chair side) |
Participating
| $60 |
Non-Participating
| $60 |
| Denture reline (lab) |
Participating
| $80 |
Non-Participating
| $80 |
DENTAL NETWORK AVAILABILITY:
The Blue Cross Small Group Voluntary PPO Dental Plan, provided by BC Life & Health Insurance Company, is available throughout the state of California. However, please note that eligible benefits are only payable at the non-participating provider level for the following |
| |
| Annual Maximum Benefit per calendar year |
Participating
| $1,000/member
(benefits paid after the deductible and applicable waiting periods are met) |
Non-Participating
| $1,000/member
(benefits paid after the deductible and applicable waiting periods are met) |
| Annual Deductible per calendar year |
Participating
| $50/person (3-member maximum) |
Non-Participating
| $50/person (3-member maximum) |
| |
| |
ORTHODONTIC CARE:
COVERAGE BEGINS UPON APPROVAL OF YOUR APPLICATION. |
| |
| Child Orthodontics |
Participating
| Up to $500 lifetime maximum per child
(participating and non-participating dentists combined) |
Non-Participating
| Up to $500 lifetime maximum per child
(participating and non-participating dentists combined) |
| |
| |
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