DT020 40820 585
Blue Choice Network
USD 466 SCOTT CITY
Effective Oct 01, 2024
This Dental Care Program offers coverage for preventive services, along with additional coverage for primary and major dental services. Employees and each eligible dependent will receive benefits for all covered services each anniversary year.
Covered Services
Inlays Simple extractions Repair of dentures Oral examinations Fillings (except gold) Fluoride (under age of 21) Emergency treatment for pain Dental imaging services required to treat or diagnose diseases or abnormalities of
PRIMARY
100% payment
the teeth, surrounding tissue, and cavity detection Prophylaxis, including cleaning, scaling and polishing Endodontics General anesthesia when the dental treatment is covered
Sealants limited to one application per tooth per lifetime per eligible insured between 5 and 17 years of age inclusive, and limited to permanent molars and bicuspids (20 teeth). Oral surgery, consisting of diagnosis and treatment of fractures, dislocations, cysts, and abscesses; and surgical extractions (including impacted teeth) Space maintainers
SUPPLEMENTAL PRIMARY
50% payment
Onlays (not part of a bridge) Crowns (not part of a bridge)
PROSTHODONTICS
Bridges Dentures, full or partial Dental implant services ($1,000 lifetime max per insured, per arch) Surgery of the bony structure supporting the teeth Periodontic treatment of the gums, consisting of examination, management and surgery
50% payment
PERIODONTICS
100% payment
Dependents under age 12
Subject to cost-sharing
ORTHODONTIC RIDER (under age of 21)
100% payment up to a 3-year maximum of $1,500
**Retention treatment Active treatment, including necessary appliances Diagnosis including study models and facial photographs Benefits are not provided for denture or bridge replacement within five years after receiving dentures or bridges under this program. Benefits are limited to standard procedures for prosthodontic services. ** If orthodontic treatment begins before the effective date of this rider, the months of previous treatment will be deducted from the maximum number of months available under this program.Note: Any charges for the replacement and/or repair of any appliance previously furnished under this plan shall not be covered byBlue Cross and Blue Shield of Kansas.
Monthly Premium
Employee
Emp/Child(ren)
Emp/Spouse
Family
Dental
$41.29
$89.35
$88.60
$136.65
An independent licensee of the Blue Cross Blue Shield Association.
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