Benefits 2007, Standard & Basic Option Dental Benefits

2007 Standard & Basic Option Service Benefit Plan Dental Benefits

This page provides a summary of the 2007 Standard and Basic Option Service Benefit Plan dental benefits. For a complete description of benefits please refer to the 2007 Blue Cross and Blue Shield Service Benefit Plan brochure (RI 71-005) online or you can call your local Blue Cross and Blue Shield Plan at the number on the back of your ID card to request one.

Standard Option Dental Benefits

What You Pay

Inpatient Hospital Care

Services

Preferred Provider

Non-Preferred Provider

Covered only when a non-dental physical impairment exists that makes hospitalization necessary to safeguard the health of the patient.

Precertification required.

Unlimited days

$100 per admission copayment

$300 per admission copayment

30% of the Plan Allowance for care in Non-member hospitals

You pay the difference between the provider's charge and our payment when you use Non-member facilities

Oral And Maxillofacial Surgery

Services

Preferred Provider

Non-Preferred Provider

See Section 5(b) of the 2007 Service Benefit Plan brochurefor limitations and covered services.

Subject to the $250 calendar year deductible

10% PPA

Subject to the calendar year deductible

25% of the Plan Allowance

You pay the difference between the provider's charge and our payment when you use Non-participating physicians

Accidental Dental Injury

Services

Preferred Provider

Non-Preferred Provider

See Section 5(h) of the 2007 Service Benefit Plan brochurefor definitions and limitations.

Subject to $250 calendar year deductible

10% PPA

Subject to the calendar year deductible

25% of the Plan Allowance

You pay the difference between the provider's charge and our payment when you use Non-participating physicians



Standard Option Routine Dental Care Benefits Under Standard Option, we pay billed charges up to the fee schedule amount for covered dental services. Below is a complete list of the covered procedures and fee schedule amounts. Any service not listed is not covered. Preferred dentists agree to accept a negotiated, discount amount called the Maximum Allowable Charge (MAC) as payment in full for these services. They will also file your claims. You are responsible for the difference between the fee schedule allowance and the MAC when you use Preferred dentists. To find a Preferred dentist near you, refer to the printed Preferred Provider Directory, check the online Provider Directory, or call your local Blue Cross and Blue Shield Plan. There are no deductibles, copayments or coinsurance. When you use Non-preferred dentists, you pay all charges in excess of the fee schedule amount.

Clinical Oral Evaluations

Services	We Pay (To Age 13)	We Pay (Age 13 And Older)	You Pay
Periodic oral evaluation* Limited oral evaluation Comprehensive oral evaluation Detailed and extensive oral evaluation	$12 $14 $14 $14	$8 $9 $9 $9	Preferred: Up to the MAC Non-preferred: Up to the provider's charge

Radiographs

Services	We Pay (To Age 13)	We Pay (Age 13 And Older)	You Pay
Intraoral complete series Intraoral periapical first film Intraoral periapical each add'l film Intraoral occlusal film Extraoral first film Extraoral each add'l film Bitewing — single film Bitewings — two films Bitewings — four films Bitewings — vertical Posterior- anterior or lateral skull and facial bone survey film Panoramic film	$36 $7 $4 $12 $16 $6 $9 $14 $19 $12 $45 $36	$22 $5 $3 $7 $10 $4 $6 $9 $12 $7 $28 $23	Preferred: Up to the MAC Non-preferred: Up to the provider's charge

Tests And Laboratory Exams

Services	We Pay (To Age 13)	We Pay (Age 13 And Older)	You Pay
Pulp vitality tests	$11	$7	Preferred: Up to the MAC Non-preferred: Up to the provider's charge

Palliative Or Emergency Treatment

Services	We Pay (To Age 13)	We Pay (Age 13 And Older)	You Pay
Palliative (emergency) treatment of dental pain — minor procedure Sedative filling	$24 $24	$15 $15	Preferred: Up to the MAC Non-preferred: Up to the provider's charge

Preventive

Services	We Pay (To Age 13)	We Pay (Age 13 And Older)	You Pay
Prophylaxis — adult* Prophylaxis — child* Topical Application of fluoride, prophylaxis included — child* Topical Application of fluoride, prophylaxis not included — child Topical Application of fluoride, prophylaxis not included — adult Topical Application of fluoride, prophylaxis included — adult*	$22 $35 $13	$16 $14 $22 $8 $8 $24	Preferred: Up to the MAC Non-preferred: Up to the provider's charge

Space Maintenance (passive appliances)

Services	We Pay (To Age 13)	We Pay (Age 13 And Older)	You Pay
Space maintainer — fixed — unilateral Space maintainer — fixed — bilateral Space maintainer — removable — unilateral Space maintainer — removable — bilateral Recementation of space maintainer	$94 $139 $94 $139 $22	$59 $87 $59 $87 $14	Preferred: Up to the MAC Non-preferred: Up to the provider's charge

Amalgam Restorations (including polishing)

Services	We Pay (To Age 13)	We Pay (Age 13 And Older)	You Pay
Amalgam — one surface, primary or permanent Amalgam — two surfaces, primary or permanent Amalgam — three surfaces, primary or permanent Amalgam — four or more surfaces, primary or permanent	$25 $37 $50 $56	$16 $23 $31 $35	Preferred: Up to the MAC Non-preferred: Up to the provider's charge

Filled Or Unfilled Resin Restorations

Services	We Pay (To Age 13)	We Pay (Age 13 And Older)	You Pay
Resin — one surface, anterior Resin — two surfaces, anterior Resin — three surfaces, anterior Resin — four or more surfaces or involving incisal angle (anterior) Resin — one surface, posterior Resin — two surfaces, posterior Resin — three surfaces, posterior Resin — four or more surfaces, posterior	$25 $37 $50 $56 $25 $37 $50 $50	$16 $23 $31 $35 $16 $23 $31 $31	Preferred: Up to the MAC Non-preferred: Up to the provider's charge

Inlay Restorations

Services	We Pay (To Age 13)	We Pay (Age 13 And Older)	You Pay
Inlay — metallic — one surface Inlay — metallic — two surfaces Inlay — metallic — three or more surfaces Inlay — porcelain/ceramic — one surface Inlay — porcelain/ceramic — two surfaces Inlay — porcelain/ceramic — three or more surfaces Inlay — composite/resin — one surface Inlay — composite/resin — two surfaces Inlay — composite/resin — three or more surfaces	$25 $37 $50 $25 $37 $50 $25 $37 $50	$16 $23 $31 $16 $23 $31 $16 $23 $31	Preferred: Up to the MAC Non-preferred: Up to the provider's charge

Other Restorative Services

Services	We Pay (To Age 13)	We Pay (Age 13 And Older)	You Pay
Pin retention — per tooth, in addition to restoration	$13	$8	Preferred: Up to the MAC Non-preferred: Up to the provider's charge

Extractions — Includes Local And Routine Post-Operative Care

Services	We Pay (To Age 13)	We Pay (Age 13 And Older)	You Pay
Extraction, erupted tooth or exposed root Surgical removal of erupted tooth requiring elevation of mucoperiosteal flap and removal of bone and/or section of tooth Surgical removal of residual tooth roots (cutting procedure) General anesthesia in connection with covered extractions	$30 $43 $71 $43	$19 $27 $45 $27	Preferred: Up to the MAC Non-preferred: Up to the provider's charge

* Limit two per person per calendar year


Basic Option Dental Benefits Basic Option benefits are not available for care performed by Non-Preferred providers, except in cases of dental care resulting from an accidental injury.

What You Pay

Inpatient Hospital Care

Services	Preferred Provider
Covered only when a non-dental physical impairment exists that makes hospitalization necessary to safeguard the health of the patient. Precertification required.	Unlimited days $100 per day up to $500

Oral And Maxillofacial Surgery

Services	Preferred Provider
See Section 5(b) of the 2007 Service Benefit Plan brochure for limitations and covered services.	$100 copayment per performing surgeon

Accidental Dental Injury

Services	Preferred Provider	Non-Preferred Provider
See Section 5(h) of the 2007 Service Benefit Plan brochure for definitions and limitations.	$20 copayment	$20 copayment Note: If you use a Non-preferred provider, you may also be responsible for any difference between our allowance and the billed amount. All follow-up care must be performed and billed for by Preferred providers to be eligible for benefits.


Basic Option Routine Dental Care Benefits Below is a complete list of the covered procedures. Any service not listed is not covered. You pay a $20 copayment for each evaluation and we pay any balances in full when you use a Preferred dentist. You must use a Preferred dentist to receive benefits, except for dental care required by an accidental injury. To locate a Preferred dentist near you, please refer to the printed Preferred Provider Directory, the online Provider Directory, or call your local Blue Cross and Blue Shield Plan.

Clinical Oral Evaluations

Services	We Pay	You Pay
Period oral evaluation* Limited oral evaluation Comprehensive oral evaluation*	All charges in excess of your $20 copayment	$20 copayment per evaluation

Radiographs

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 $20 copayment	$20 copayment per evaluation

Preventive

Services	We Pay	You Pay
Prophylaxis — adult (up to 2 per calendar year) Prophylaxis — child (up to 2 per calendar year)* Topical application of fluoride (including prophylaxis) — child (up to 2 per calendar year)* Topical application of fluoride (prophylaxis not included) — child (up to 2 per calendar year) Sealant — per tooth, first and second molars only (once per tooth for children up to age 16 only)	All charges in excess of your $20 copayment	$20 copayment per evaluation

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

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

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

2007 SERVICE BENEFIT PLAN BENEFITS

2007 BENEFITS

BENEFITS