Dental Blue
Your dental benefits provide coverage for
diagnostic and preventive care, as well as, basic services and major services.
Plus, you may obtain services from any licensed dentist. The chart below
describes how your dental plan works:
| Type of Coverage | Plan Benefits1 |
| Preventive
Services Routine oral exams Adult & child cleaning Bitewing x-rays Pulp testing Annual fluoride cleaning (members under 18-years-old only) Palliative emergency treatment & emergency oral examinations Other diagnostic & preventive services |
100% |
| Basic
Services Routine fillings Sealants (members 5 - 15-years-old only) Space maintainers (members under 16-years-old) Endodontics Simple extractions Oral surgery Other basic services |
60% |
| Major
Services Gingival curettage Gingivectomy and gingivoplasty Periodontal maintenance Inlays and onlays (once per 5 years) Crowns Dentures Bridges Other major services |
50% |
| Deductible, basic and major services | $75 |
| Annual maximum, all services2 | $1,000 |
| Waiting periods | |
| Diagnostic & Preventive Services | None |
| Basic Services | 6 months |
| Major Services | 12 months |
Dental Blue for Individuals
Limitations and Exclusions
Like most health care plans, Dental Blue® for Individuals has some limitations
and exclusions.
1.Based on allowed amount, as determined by Blue Cross Blue Shield of NC. The allowed amount may be substantially less than the provider’s actual charge. You will be responsible for the charges above the allowed amount, in addition to any deductible and coinsurance applied.