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 and child cleaning,
Bitewing X-rays,
Sealants (members 5 to 15 years old only),
Pulp testing,
Fluoride cleaning (members through 18 years old only),
Palliative emergency treatment,
Emergency oral examinations,
Other diagnostic and preventive services
|
100% |
Basic Services
Fillings, Space maintainers (members under 16 years old only),
Endodontics,
Simple extractions,
Oral surgery,
Other basic services
|
60% |
Major Services
Gingiva l curettage,
Gingivectomy and gingivoplasty,
Periodontal maintenance,
Inlays and onlays (once per 5 years),
Crowns and bridges,
Dentures,
Other major services
|
50% |
Deductible
basic and major services |
$75 |
Annual maximum, all services
(per covered member) |
$1,000 |
Waiting periods
Diagnostic and preventive services / Basic services / Major services |
None / 6 months / 12 months |
| Waiting periods |
| Diagnostic & Preventive Services |
None |
| Basic Services |
6 months |
| Major Services |
12 months |
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.
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: