Xpress Global Systems • 2023 Benefit Guide
DENTAL BLUECROSS BLUESHIELD OF TN 800-565-9140 | BCBST.COM
Although you can choose any dental provider, when you use an in-network dentist, you will generally pay less. If you choose an out-of-network provider, you may be billed the difference between what BlueCross BlueShield of Tenessee pays, and what your out-of-network provider charges for the services. To locate an in-network provider, please visit bcbst.com/finddentalcare .
Dental
Low Plan
High Plan
Annual deductible (Individual/Family)
$50 / $150
$50 / $150
Annual maximum (per person)
$1,000
$2,000
Diagnostic and preventive care Includes cleanings, fluoride treatments, sealants and x-rays
100% covered
100% covered
Basic services Includes fillings, periodontics, scaling and root planning, and oral surgery
50% covered after ded.
90% covered after ded.
Major services Includes crowns, bridges and full and partial dentures
50% covered after ded.
60% covered after ded.
50% covered $2,000 lifetime max
Orthodontia (Children up to age 19)
Not covered
Plan includes out-of-network benefits, see plan summary for additional details.
VISION BLUECROSS BLUESHIELD OF TN 800-565-9140 | BCBST.COM
Our vision care benefits include coverage for eye exams, lenses and frames, contact lenses, and discounts for laser surgery. The vision plan is built around the providers, who have higher benefits at a lower cost to you. When you need services, consider using an in-network provider for the most bang for your buck! When you use an out-of-network provider, you will be reimbursed for services according to the grid below. To locate an in-network provider, visit BCBST.com.
Vision
In-network
Examination (every 12 months)
$20
Material
$20
Lenses
(every 12 months)
Single
Bifocal Trifocal Frames
Covered in full after materials copay
(every 24 months)
New frames
$135 allowance
Contact lenses
(every 12 months)
Elective
$135 copay
Employees can elect dental and/or vision regardless of whether they are enrolled in medical.
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