Blue Chip
Insurance Agency, Inc.

Blue Advantage® | Blue Options HSA® | Blue Medicare® | Group Plans® | Student Plans®

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.