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Dental

Basic Option offers coverage for a number of routine dental care procedures. For each evaluation you pay a $25 copayment and the Blue Cross and Blue Shield Service Benefit Plan takes care of the rest. In order to receive benefits, you must use a Preferred dentist, except if dental care is required due to an accidental injury.

Below is a complete list of the routine dental services that are covered under Basic Option. Any service not listed is not covered.

Clinical Oral Evaluations

ServicesWe PayYou Pay

Periodic oral evaluation*

Limited oral evaluation

Comprehensive oral evaluation*

All charges in excess of your $25 copayment

$25 copayment per evaluation

Diagnostic Imaging

ServicesWe PayYou Pay

Intraoral complete series, including bitewings (limited to 1 complete series every 3 years)

Bitewing — single image**

Bitewings — two images**

Bitewings — four images**

All charges in excess of your $25 copayment

$25 copayment per evaluation

Preventive

ServicesWe PayYou Pay

Prophylaxis — adult***

Prophylaxis — child***

Topical application of fluoride or fluoride varnish — for children only***

Sealant — per tooth, first and second molars only (once per tooth for children up to age 16 only)

All charges in excess of your $25 copayment

$25 copayment per evaluation

Not covered: Any service not specifically listed above

Nothing

All charges

* Benefits are limited to a combined total of two evaluations per person per calendar year.

** Benefits are limited to a combined total of four images per person per calendar year.

*** Benefits are limited to a combined total of two services per person per calendar year.

Page last updated: November 15, 2013

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