BlueCare® Dental PPO
Optional Dental Coverage
BlueCare® Dental PPO Plan Benefit Highlights Chart
| Benefits1 | Participating Dentists | Non-Participating Dentists2 |
|---|---|---|
| Deductible Deductible applies to Type III Services Only |
$50 per member per benefit period; $150 maximum per family |
|
| Calendar Year Maximum Benefit (per individual) |
$1,5002 | |
| Type I Services Cleanings Examinations X-rays Sealants Space maintainers |
100% of Maximum Allowance | 50% of Maximum Allowance |
| Type II Services Fillings Simple Extractions |
80% of Maximum Allowance | 50% of Maximum Allowance |
| Type III Services Bridges3 Crowns3 Dentures3 Endodontics Oral Surgery Periodontics |
50% of Maximum Allowance after deductible | 50% of Maximum Allowance after deductible |
1 Your dental care benefits are highlighted in this chart. To fully understand all the terms, conditions, limitations and exclusions which apply to your benefits, please read the entire BlueCare Dental PPO Rider.
2 For services received from a non-participating dentist, the member will be responsible for any difference between the dentist’s charges and the maximum allowable charge. The maximum allowable charge is based on our network negotiated fees. Further information regarding the maximum allowable charge and network status of dentists is available by calling the toll free telephone number on the back of your dental identification card.
3 Benefit Waiting Period – You must be continuously covered under your rider for twelve (12) months before being eligible for the following covered services: (1) Major Restorative Services; (2) Prosthodontic Services; and (3) Miscellaneous Restorative and Prosthodontic Services.
