Dental
Basic Option offers coverage for a number of routine dental care procedures. For each evaluation you pay a $25 copayment and Blue Cross Blue Shield 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 covered procedures and fee schedule amounts. Any service not listed is not covered.
Clinical Oral Evaluations
| Services | We Pay | You Pay |
|---|---|---|
Periodic oral evaluation* Limited oral evaluation Comprehensive oral evaluation* | All charges in excess of your $25 copayment | $25 copayment per evaluation |
Dental Radiology
| Services | We Pay | You Pay |
|---|---|---|
Intraoral complete series, including bitewings (limited to 1 complete series every 3 years) Bitewing — single film** Bitewings — two films** Bitewings — four films** | All charges in excess of your $25 copayment | $25 copayment per evaluation |
Preventive
| Services | We Pay | You Pay |
|---|---|---|
Prophylaxis — adult*** Prophylaxis — child*** Topical application of fluoride (prophylaxis not included) — child*** 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 |
Page last updated: December 19, 2012