Dental Blue® - Summary
of Benefits |
|
Your dental benefits provide coverage for diagnostic
and preventive care, basic services and major services. Plus, you may
obtain services from any provider. The chart below describes how your
dental plan works:
| Type of Coverage |
Plan Benefits |
| Preventive Service - Deductible does not apply |
|
 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 - Subject to $75 calendar year
deductible |
|
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 - Subject to $75 calendar year
deductible |
|
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 services |
$1,000 |
|
| Waiting
Periods |
| Diagnostic
Preventive Services None |
| Basic
Services 6 months |
| Major
Services 12 months |
*Based on allowed amount, as determined by BCBSNC®.
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.
When
Does My Dental Blue® Coverage Begin?
If your application is received on or before the 20th of the month, your
coverage will be effective on the first day of the next month. If your
application is received after the 20th, coverage will take effect on
the first day of the following month.
For example, coverage for an application received May
19th will begin on June 1st. Coverage for an application received May
21st will begin July 1st.
Are
There Any Waiting Periods for Preventative Services?
You don't have to wait to receive preventive services with Dental Blue®.
That means you can get your checkups when you need them. And most preventive
services are covered twice per benefit period. So, you can protect your
teeth by visiting the dentist every six months.
Can
I Choose The Dentist I like?
Dental Blue® doesn't limit your choice of dentists, and you don't
have to stay "in-network." Choose any North Carolina licensed
dentist you like, in any town. No network, and no geographic restrictions.
What
Will Dental Blue® Cost?
You can purchase Dental Blue® coverage for you, your child or your
entire family. There are three payment options, including a convenient
monthly bank draft. Click on the link below to access rates.
Dental
Blue® Rates
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