Blue Cross and Blue Shield Service Benefit Plan.
2008 Standard And Basic Option Service Benefit Plan Dental Benefits.
This section provides a summary of the 2008 Standard and Basic Option Service Benefit Plan dental benefits.
For a complete explanation of your benefits please see the 2008 Service Benefit Plan brochure. If you do not have a 2008 brochure, you can call your local Blue Cross and Blue Shield Plan at the number on the back of your ID card to request one.
Click on any of the section links that follow or scroll down to learn about dental benefits for Standard And Basic Options in 2008.
2008 Standard Option Dental Benefits.
1. Inpatient Hospital Care.
Hospitalization for severe dental caries in children up to age 22 and for other types of dental procedures when a non-dental physical impairment makes hospitalization necessary to safeguard the health of the patient. Unlimited days. Precertification is required and you pay:
When you use a Preferred provider:
You pay the $100 per admission co-payment.
When you use a Non-Preferred provider:
You pay the $300 per admission co-payment.
You pay 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.
2. Oral And Maxilofacial Surgery.
For covered service, see section 5(b) of the 2008 Service Benefit Plan brochure for limitations and covered service, you pay:
When you use a Preferred provider:
You are subject to the $300 calendar year deductible.
You pay 10% of the Preferred Provider Allowance.
When you use a Non-Preferred provider:
You are subject to the $300 calendar year deductible.
You pay 25% of the Plan Allowance.
You pay the difference between the provider's charge and our payment when you use Non-participating physicians.
3. Accidental Dental Surgery.
When you use a Preferred provider:
You are subject to the $300 calendar year deductible.
You pay 10% of the Preferred Provider Allowance for physician care.
You pay 15% of the Preferred Provider Allowance for facility care.
When you use a Non-Preferred provider:
You are subject to the $300 calendar year deductible.
You pay 25% of the Plan Allowance for physician care.
You pay 30% of the Plan Allowance for facility care.
You pay the difference between the provider's charge and our payment when you use Non-participating physicians.
4. Routine Dental Care.
Under Standard Option, we pay billed charges up to the fee schedule amounts for covered dental services. Following 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 or (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, co-payments or co-insurance. When you use Non-preferred dentists you pay all charges in excess of the fee schedule amount.
Clinical Oral Evaluation Services:
(a). Periodic Oral Evaluation, Up To Two Per Person, Per Calendar Year.
We pay:
Up to age 13 we pay $12.
Age 13 and older we pay $8.
You pay:
For Preferred up to the Maximum Allowable Charge.
For Non-Preferred up to the provider's charge.
(b). Limited Oral Evaluation.
We pay:
Up to age 13 we pay $14.
Age 13 and older we pay $9.
You pay:
For Preferred up to the Maximum Allowable Charge.
For Non-Preferred up to the provider's charge.
(c). Comprehensive Oral Evaluation.
We pay:
Up to age 13 we pay $14.
Age 13 and older we pay $9.
You pay:
For Preferred up to the Maximum Allowable Charge.
For Non-Preferred up to the provider's charge.
(d). Detailed And Extensive Oral Evaluation.
We pay:
Up to age 13 we pay $14.
Age 13 and older we pay $9.
You pay:
For Preferred up to the Maximum Allowable Charge.
For Non-Preferred up to the provider's charge.
Radiograph Services:
(a). Intraoral Complete Series.
We pay:
Up to age 13 we pay $36.
Age 13 and older we pay $22.
You pay:
For Preferred up to the Maximum Allowable Charge.
For Non-Preferred up to the provider's charge.
(b). Intraoral Periapical First Film.
We pay:
Up to age 13 we pay $7.
Age 13 and older we pay $5.
You pay:
For Preferred up to the Maximum Allowable Charge.
For Non-Preferred up to the provider's charge.
(c). Intraoral Periapical Each Additional Film.
We pay:
Up to age 13 we pay $4.
Age 13 and older we pay $3.
You pay:
For Preferred up to the Maximum Allowable Charge.
For Non-Preferred up to the provider's charge.
(d). Intraoral Occlusal Film.
We pay:
Up to age 13 we pay $12.
Age 13 and older we pay $7.
You pay:
For Preferred up to the Maximum Allowable Charge.
For Non-Preferred up to the provider's charge.
(e). Extraoral First Film.
We pay:
Up to age 13 we pay $16.
Age 13 and older we pay $10.
You pay:
For Preferred up to the Maximum Allowable Charge.
For Non-Preferred up to the provider's charge.
(f). Extraoral Each Additional Film.
We pay:
Up to age 13 we pay $6.
Age 13 and older we pay $4.
You pay:
For Preferred up to the Maximum Allowable Charge.
For Non-Preferred up to the provider's charge.
(g). Bitewing Single Film.
We pay:
Up to age 13 we pay $9.
Age 13 and older we pay $6.
You pay:
For Preferred up to the Maximum Allowable Charge.
For Non-Preferred up to the provider's charge.
(h). Bitewings Two Films.
We pay:
Up to age 13 we pay $14.
Age 13 and older we pay $9.
You pay:
For Preferred up to the Maximum Allowable Charge.
For Non-Preferred up to the provider's charge.
(i). Bitewings Four Films.
We pay:
Up to age 13 we pay $19.
Age 13 and older we pay $12.
You pay:
For Preferred up to the Maximum Allowable Charge.
For Non-Preferred up to the provider's charge.
(j). Bitewings Vertical.
We pay:
Up to age 13 we pay $12.
Age 13 and older we pay $7.
You pay:
For Preferred up to the Maximum Allowable Charge.
For Non-Preferred up to the provider's charge.
(k). Posterior, Anterior Or Lateral Skull And Facial Bone Survey Film.
We pay:
Up to age 13 we pay $45.
Age 13 and older we pay $28.
You pay:
For Preferred up to the Maximum Allowable Charge.
For Non-Preferred up to the provider's charge.
(l). Panoramic Film.
We pay:
Up to age 13 we pay $36.
Age 13 and older we pay $23.
You pay:
For Preferred up to the Maximum Allowable Charge.
For Non-Preferred up to the provider's charge.
Tests And Laboratory Exams Services:
(a). Pulp Vitality Tests.
We pay:
Up to age 13 we pay $11.
Age 13 and older we pay $7.
You pay:
For Preferred up to the Maximum Allowable Charge.
For Non-Preferred up to the provider's charge.
Palliative Or Emergency Treatment Services
(a). Palliative Emergency Treatment Of Dental Pain, Minor Procedure.
We pay:
Up to age 13 we pay $24.
Age 13 and older we pay $15.
You pay:
For Preferred up to the Maximum Allowable Charge.
For Non-Preferred up to the provider's charge.
(b). Sedative Filling.
We pay:
Up to age 13 we pay $24.
Age 13 and older we pay $15.
You pay:
For Preferred up to the MAC.
For Non-Preferred up to the provider's charge.
Preventive Services:
(a). Prophylaxis For Adult, Up to Two Per Person Per Calendar Year.
We pay:
Age 13 and older we pay $16.
You pay:
For Preferred up to the Maximum Allowable Charge.
For Non-Preferred up to the provider's charge.
(b). Prophylaxis For Child, Up to Two Per Person Per Calendar Year.
We pay:
Up to age 13 we pay $22.
Age 13 and older we pay $14.
You pay:
For Preferred up to the Maximum Allowable Charge.
For Non-Preferred up to the provider's charge.
(c). Topical Application Of Fluoride For Child, Prophylaxis Included, Up to Two Per Person Per Calendar Year.
We pay:
Up to age 13 we pay $35.
Age 13 and older we pay $22.
You pay:
For Preferred up to the Maximum Allowable Charge.
For Non-Preferred up to the provider's charge.
(d). Topical Application Of Fluoride For Child, Prophylaxis Not Included.
We pay:
Up to age 13 we pay $13.
Age 13 and older we pay $8.
You pay:
For Preferred up to the Maximum Allowable Charge.
For Non-Preferred up to the provider's charge.
(e). Topical Application Of Fluoride For Adult, Prophylaxis Not Included.
We pay:
Age 13 and older we pay $8.
You pay:
For Preferred up to the Maximum Allowable Charge.
For Non-Preferred up to the provider's charge.
(f). Topical Application Of Fluoride For Adult, Prophylaxis Included, Up to Two Per Person Per Calendar Year.
We pay:
Age 13 and older we pay $24.
You pay:
For Preferred up to the Maximum Allowable Charge.
For Non-Preferred up to the provider's charge.
Space Maintenance And Passive Appliances Services:
(a). Space Maintainer, Fixed And Unilateral.
We pay:
Up to age 13 we pay $94.
Age 13 and older we pay $59.
You pay:
For Preferred up to the Maximum Allowable Charge.
For Non-Preferred up to the provider's charge.
(b). Space Maintainer, Fixed And Bilateral.
We pay:
Up to age 13 we pay $139.
Age 13 and older we pay $87.
You pay:
For Preferred up to the Maximum Allowable Charge.
For Non-Preferred up to the provider's charge.
(c). Space Maintainer, Removable And Unilateral.
We pay:
Up to age 13 we pay $94.
Age 13 and older we pay $59.
You pay:
For Preferred up to the Maximum Allowable Charge.
For Non-Preferred up to the provider's charge.
(d). Space Maintainer, Removable And Bilateral.
We pay:
Up to age 13 we pay $139.
Age 13 and older we pay $87.
You pay:
For Preferred up to the Maximum Allowable Charge.
For Non-Preferred up to the provider's charge.
(e). Recementation Of Space Maintainer.
We pay:
Up to age 13 we pay $22.
Age 13 and older we pay $14.
You pay:
For Preferred up to the Maximum Allowable Charge.
For Non-Preferred up to the provider's charge.
Amalgam Restoration, Including Polishing, Services:
(a). Amalgam, One Surface, Primary Or Permanent.
We pay:
Up to age 13 we pay $25.
Age 13 and older we pay $16.
You pay:
For Preferred up to the Maximum Allowable Charge.
For Non-Preferred up to the provider's charge.
(b). Amalgam, Two Surfaces, Primary Or Permanent.
We pay:
Up to age 13 we pay $37.
Age 13 and older we pay $23.
You pay:
For Preferred up to the Maximum Allowable Charge.
For Non-Preferred up to the provider's charge.
(c). Amalgam, Three Surfaces, Primary Or Permanent.
We pay:
Up to age 13 we pay $50.
Age 13 and older we pay $31.
You pay:
For Preferred up to the Maximum Allowable Charge.
For Non-Preferred up to the provider's charge.
(d). Amalgam, Four Or More Surfaces, Primary Or Permanent.
We pay:
Up to age 13 we pay $56.
Age 13 and older we pay $35.
You pay:
For Preferred up to the Maximum Allowable Charge.
For Non-Preferred up to the provider's charge.
Filled Or Unfilled Resin Restoration Care:
(a). Resin, One Surface, Anterior.
We pay:
Up to age 13 we pay $25.
Age 13 and older we pay $16.
You pay:
For Preferred up to the Maximum Allowable Charge.
For Non-Preferred up to the provider's charge.
(b). Resin, Two Surfaces, Anterior.
We pay:
Up to age 13 we pay $37.
Age 13 and older we pay $23.
You pay:
For Preferred up to the Maximum Allowable Charge.
For Non-Preferred up to the provider's charge.
(c). Resin, Three Surfaces, Anterior.
We pay:
Up to age 13 we pay $50.
Age 13 and older we pay $31.
You pay:
For Preferred up to the Maximum Allowable Charge.
For Non-Preferred up to the provider's charge.
(d). Resin, Four Or More Surfaces Or Involving Incisal Angle, Anterior.
We pay:
Up to age 13 we pay $56.
Age 13 and older we pay $35.
You pay:
For Preferred up to the Maximum Allowable Charge.
For Non-Preferred up to the provider's charge.
(e). Resin, One Surface, Posterior.
We pay:
Up to age 13 we pay $25.
Age 13 and older we pay $16.
You pay:
For Preferred up to the Maximum Allowable Charge.
For Non-Preferred up to the provider's charge.
(f). Resin, Two Surfaces, Posterior.
We pay:
Up to age 13 we pay $37.
Age 13 and older we pay $23.
You pay:
For Preferred up to the Maximum Allowable Charge.
For Non-Preferred up to the provider's charge.
(g). Resin, Three Surfaces, Posterior.
We pay:
Up to age 13 we pay $50.
Age 13 and older we pay $31.
You pay:
For Preferred up to the Maximum Allowable Charge.
For Non-Preferred up to the provider's charge.
(h). Resin, Four Or More Surfaces, Posterior.
We pay:
Up to age 13 we pay $50.
Age 13 and older we pay $31.
You pay:
For Preferred up to the Maximum Allowable Charge.
For Non-Preferred up to the provider's charge.
Inlay Restoration Care:
(a). Inlay, Metallic, One Surface.
We pay:
Up to age 13 we pay $25.
Age 13 and older we pay $16.
You pay:
For Preferred up to the Maximum Allowable Charge.
For Non-Preferred up to the provider's charge.
(b). Inlay, Metallic, Two Surfaces.
We pay:
Up to age 13 we pay $37.
Age 13 and older we pay $23.
You pay:
For Preferred up to the Maximum Allowable Charge.
For Non-Preferred up to the provider's charge.
(c). Inlay, Metalic, Three Or More Surfaces.
We pay:
Up to age 13 we pay $50.
Age 13 and older we pay $31.
You pay:
For Preferred up to the Maximum Allowable Charge.
For Non-Preferred up to the provider's charge.
(d). Inlay, Porcelain / Ceramic, One Surface.
We pay:
Up to age 13 we pay $25.
Age 13 and older we pay $16.
You pay:
For Preferred up to the Maximum Allowable Charge.
For Non-Preferred up to the provider's charge.
(e). Inlay, Porcelain / Ceramic, Two Surfaces.
We pay:
Up to age 13 we pay $37.
Age 13 and older we pay $23.
You pay:
For Preferred up to the Maximum Allowable Charge.
For Non-Preferred up to the provider's charge.
(f). Inlay, Porcelain / Ceramic, Three Or More Surfaces.
We pay:
Up to age 13 we pay $50.
Age 13 and older we pay $31.
You pay:
For Preferred up to the Maximum Allowable Charge.
For Non-Preferred up to the provider's charge.
(g). Inlay, Composite / Resin, One Surface.
We pay:
Up to age 13 we pay $25.
Age 13 and older we pay $16.
You pay:
For Preferred up to the Maximum Allowable Charge.
For Non-Preferred up to the provider's charge.
(h). Inlay, Composite / Resin, Two Surfaces.
We pay:
Up to age 13 we pay $37.
Age 13 and older we pay $23.
You pay:
For Preferred up to the Maximum Allowable Charge.
For Non-Preferred up to the provider's charge.
(i). Inlay, Composite / Resin, Three Or More Surfaces.
We pay:
Up to age 13 we pay $50.
Age 13 and older we pay $31.
You pay:
For Preferred up to the Maximum Allowable Charge.
For Non-Preferred up to the provider's charge.
Other Restorative Services:
(a). Pin Retention, Per Tooth, In Addition To Restoration.
We pay:
Up to age 13 we pay $13.
Age 13 and older we pay $8.
You pay:
For Preferred up to the Maximum Allowable Charge.
For Non-Preferred up to the provider's charge.
Extractions - Includes Local And Routine Post-Operative Care:
(a). Extractions, Erupted Tooth Or Exposed Root.
We pay:
Up to age 13 we pay $30.
Age 13 and older we pay $19.
You pay:
For Preferred up to the Maximum Allowable Charge.
For Non-Preferred up to the provider's charge.
(b). Surgical Removal Of Erupted Tooth Requiring Elevation Of Mucoperiosteal Flap And Removal Of Bone And / Or Section Of Tooth.
We pay:
Up to age 13 we pay $43.
Age 13 and older we pay $27.
You pay:
For Preferred up to the Maximum Allowable Charge.
For Non-Preferred up to the provider's charge.
(c). Surgical Removal Of Residual Tooth Roots, Cutting Procedure.
We pay:
Up to age 13 we pay $71.
Age 13 and older we pay $45.
You pay:
For Preferred up to the Maximum Allowable Charge.
For Non-Preferred up to the provider's charge.
(d). General Anesthesia In Connection With Covered Extractions.
We pay:
Up to age 13 we pay $43.
Age 13 and older we pay $27.
You pay:
For Preferred up to the Maximum Allowable Charge.
For Non-Preferred up to the provider's charge.
2008 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.
1. Inpatient Hospital Care.
Hospitalization for severe dental caries in children up to the age of 22 and for other types of dental procedures when a non-dental physical impairment makes hospitalization necessary to safeguard the health of the patient. Precertification is required and you pay:
When you use a Preferred provider:
You pay the $100 per day up to $500 for unlimited days.
2. Oral And Maxillofacial Surgery.
For covered service, see section 5(b) of the 2008 Service Benefit Plan brochure for limitations and covered service, you pay:
When you use a Preferred provider:
You pay a $100 co-payment per performing surgeon.
3. Accidental Dental Surgery.
When you use a Preferred provider:
You pay the $20 co-payment.
Note: When you use a Non-preferred provider, you pay the $20 co-payment and any difference between our payment and the billed amount. All follow-up care must be performed and billed by Preferred providers to be eligible for benefits.
4. Routine Dental Care.
Following is a complete list of the covered procedures. Any service not listed is not covered.
You pay a $20 co-payment. 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, please refer to the printed Preferred Provider Directory, the online Provider Directory, or call your local Blue Cross and Blue Shield Plan.
Clinical Oral Evaluation Services:
(a). Periodic Oral Evaluation, Limited Oral Evaluation, And Comprehensive Oral Evaluation.
Please Note: For Periodic Oral Evaluations and Comprehensive Oral Evaluations, benefits are limited to a combined total of two evaluations and two prophylaxis per person per calendar year.
We pay, when you use a Preferred provider:
All charges in excess of your $20 co-payment.
You pay, when you use a Preferred provider:
The $20 co-payment per evaluation.
Radiograph Services:
(a). Intraoral Complete Series Including Bitewings (limited to one complete series every three years); Bitewing, Single film; Bitewings, Two Films; Bitewings, Four Films.
Please Note: Benefits are limited to a combined total of four films per person per calendar year.
We pay, when you use a Preferred provider:
All charges in excess of your $20 co-payment.
You pay, when you use a Preferred provider:
The $20 co-payment per evaluation.
Preventive Services:
Please Note: Benefits are limited to a combined total of two visits per person for prophylaxis for a child and topical application of fluoride including prophylaxis.
(a). Prophylaxis For Adult And Child, Up To Two Per Calendar Year.
We pay, when you use a Preferred provider:
All charges in excess of your $20 co-payment.
You pay, when you use a Preferred provider:
The $20 co-payment per evaluation.
(b). Topical Application Of Fluoride For Child, Including Or Not Including Prophylaxis, Up To Two Per Calendar Year.
Please Note: Benefits are limited to a combined total of two visits per person per calendar year.
We pay, when you use a Preferred provider:
All charges in excess of your $20 co-payment.
You pay, when you use a Preferred provider:
The $20 co-payment per evaluation.
(c). Sealant For Children Up To Age 16 Only, Once Per Tooth, First And Second Molars Only.
We pay, when you use a Preferred provider:
All charges in excess of your $20 co-payment.
You pay, when you use a Preferred provider:
The $20 co-payment per evaluation.