2023 Blue Cross and Blue Shield Service Benefit Plan - Standard and Basic Option
Section 5(g). Dental Benefits
Page 123
Section 5(g). Dental Benefits
Page 123
Standard Option Dental Benefits
Under Standard Option, we pay billed charges for the following services, up to the amounts shown per service as listed in the Schedule of Dental Allowances below and on the following page. This is a complete list of dental services covered under this benefit for Standard Option. There are no deductibles, copayments, or coinsurance. When you use non-preferred dentists, you pay all charges in excess of the listed fee schedule amounts. For Preferred dentists, you pay the difference between the fee schedule amount and the MAC (see page 122).
Under Standard Option, we pay billed charges for the following services, up to the amounts shown per service as listed in the Schedule of Dental Allowances below and on the following page. This is a complete list of dental services covered under this benefit for Standard Option. There are no deductibles, copayments, or coinsurance. When you use non-preferred dentists, you pay all charges in excess of the listed fee schedule amounts. For Preferred dentists, you pay the difference between the fee schedule amount and the MAC (see page 122).
Standard Option Dental Benefits
Clinical oral evaluations
Covered Service: Periodic oral evaluation (up to 2 per person per calendar year)
We Pay to Age 13: $12
We Pay Age 13 and Over: $8
You Pay: All charges in excess of the scheduled amounts listed above
Note: For services performed by dentists and oral surgeons in our Preferred Dental Network, you pay the difference between the amounts listed above and the Maximum Allowable Charge (MAC).
Covered Service: Limited oral evaluation
We Pay to Age 13: $14
We Pay Age 13 and Over: $9
You Pay: All charges in excess of the scheduled amounts listed above
Note: For services performed by dentists and oral surgeons in our Preferred Dental Network, you pay the difference between the amounts listed above and the Maximum Allowable Charge (MAC).
Covered Service: Comprehensive oral evaluation
We Pay to Age 13: $14
We Pay Age 13 and Over: $9
You Pay: All charges in excess of the scheduled amounts listed above
Note: For services performed by dentists and oral surgeons in our Preferred Dental Network, you pay the difference between the amounts listed above and the Maximum Allowable Charge (MAC).
Covered Service: Detailed and extensive oral evaluation
We Pay to Age 13: $14
We Pay Age 13 and Over: $9
You Pay: All charges in excess of the scheduled amounts listed above
Note: For services performed by dentists and oral surgeons in our Preferred Dental Network, you pay the difference between the amounts listed above and the Maximum Allowable Charge (MAC).
Clinical oral evaluations
Covered Service: Periodic oral evaluation (up to 2 per person per calendar year)
We Pay to Age 13: $12
We Pay Age 13 and Over: $8
You Pay: All charges in excess of the scheduled amounts listed above
Note: For services performed by dentists and oral surgeons in our Preferred Dental Network, you pay the difference between the amounts listed above and the Maximum Allowable Charge (MAC).
Covered Service: Limited oral evaluation
We Pay to Age 13: $14
We Pay Age 13 and Over: $9
You Pay: All charges in excess of the scheduled amounts listed above
Note: For services performed by dentists and oral surgeons in our Preferred Dental Network, you pay the difference between the amounts listed above and the Maximum Allowable Charge (MAC).
Covered Service: Comprehensive oral evaluation
We Pay to Age 13: $14
We Pay Age 13 and Over: $9
You Pay: All charges in excess of the scheduled amounts listed above
Note: For services performed by dentists and oral surgeons in our Preferred Dental Network, you pay the difference between the amounts listed above and the Maximum Allowable Charge (MAC).
Covered Service: Detailed and extensive oral evaluation
We Pay to Age 13: $14
We Pay Age 13 and Over: $9
You Pay: All charges in excess of the scheduled amounts listed above
Note: For services performed by dentists and oral surgeons in our Preferred Dental Network, you pay the difference between the amounts listed above and the Maximum Allowable Charge (MAC).
Standard Option Dental Benefits
Diagnostic imaging
Covered Service: Intraoral complete series
We Pay to Age 13: $36
We Pay Age 13 and Over: $22
You Pay: All charges in excess of the scheduled amounts listed above
Note: For services performed by dentists and oral surgeons in our Preferred Dental Network, you pay the difference between the amounts listed above and the Maximum Allowable Charge (MAC).
Diagnostic imaging
Covered Service: Intraoral complete series
We Pay to Age 13: $36
We Pay Age 13 and Over: $22
You Pay: All charges in excess of the scheduled amounts listed above
Note: For services performed by dentists and oral surgeons in our Preferred Dental Network, you pay the difference between the amounts listed above and the Maximum Allowable Charge (MAC).
Standard Option Dental Benefits
Palliative treatment
Covered Service: Palliative treatment of dental pain – minor procedure
We Pay to Age 13: $24
We Pay Age 13 and Over: $15
You Pay: All charges in excess of the scheduled amounts listed above
Note: For services performed by dentists and oral surgeons in our Preferred Dental Network, you pay the difference between the amounts listed above and the Maximum Allowable Charge (MAC).
Covered Service: Protective restoration
We Pay to Age 13: $24
We Pay Age 13 and Over: $15
You Pay: All charges in excess of the scheduled amounts listed above
Note: For services performed by dentists and oral surgeons in our Preferred Dental Network, you pay the difference between the amounts listed above and the Maximum Allowable Charge (MAC).
Palliative treatment
Covered Service: Palliative treatment of dental pain – minor procedure
We Pay to Age 13: $24
We Pay Age 13 and Over: $15
You Pay: All charges in excess of the scheduled amounts listed above
Note: For services performed by dentists and oral surgeons in our Preferred Dental Network, you pay the difference between the amounts listed above and the Maximum Allowable Charge (MAC).
Covered Service: Protective restoration
We Pay to Age 13: $24
We Pay Age 13 and Over: $15
You Pay: All charges in excess of the scheduled amounts listed above
Note: For services performed by dentists and oral surgeons in our Preferred Dental Network, you pay the difference between the amounts listed above and the Maximum Allowable Charge (MAC).
Standard Option Dental Benefits
Preventive
Covered Service: Prophylaxis – adult (up to 2 per person per calendar year)
We Pay to Age 13: ---
We Pay Age 13 and Over: $16
You Pay: All charges in excess of the scheduled amounts listed above
Note: For services performed by dentists and oral surgeons in our Preferred Dental Network, you pay the difference between the amounts listed above and the Maximum Allowable Charge (MAC).
Covered Service: Prophylaxis – child (up to 2 per person per calendar year)
We Pay to Age 13: $22
We Pay Age 13 and Over: $14
You Pay: All charges in excess of the scheduled amounts listed above
Note: For services performed by dentists and oral surgeons in our Preferred Dental Network, you pay the difference between the amounts listed above and the Maximum Allowable Charge (MAC).
Covered Service: Topical application of fluoride or fluoride varnish (up to 2 per person per calendar year)
We Pay to Age 13: $13
We Pay Age 13 and Over: $8
You Pay: All charges in excess of the scheduled amounts listed above
Note: For services performed by dentists and oral surgeons in our Preferred Dental Network, you pay the difference between the amounts listed above and the Maximum Allowable Charge (MAC).
Preventive
Covered Service: Prophylaxis – adult (up to 2 per person per calendar year)
We Pay to Age 13: ---
We Pay Age 13 and Over: $16
You Pay: All charges in excess of the scheduled amounts listed above
Note: For services performed by dentists and oral surgeons in our Preferred Dental Network, you pay the difference between the amounts listed above and the Maximum Allowable Charge (MAC).
Covered Service: Prophylaxis – child (up to 2 per person per calendar year)
We Pay to Age 13: $22
We Pay Age 13 and Over: $14
You Pay: All charges in excess of the scheduled amounts listed above
Note: For services performed by dentists and oral surgeons in our Preferred Dental Network, you pay the difference between the amounts listed above and the Maximum Allowable Charge (MAC).
Covered Service: Topical application of fluoride or fluoride varnish (up to 2 per person per calendar year)
We Pay to Age 13: $13
We Pay Age 13 and Over: $8
You Pay: All charges in excess of the scheduled amounts listed above
Note: For services performed by dentists and oral surgeons in our Preferred Dental Network, you pay the difference between the amounts listed above and the Maximum Allowable Charge (MAC).
Standard Option Dental Benefits
Covered Service: Not covered: Any service not specifically listed above
We Pay to Age 13: Nothing
We Pay Age 13 and Over: Nothing
You Pay: All charges
Covered Service: Not covered: Any service not specifically listed above
We Pay to Age 13: Nothing
We Pay Age 13 and Over: Nothing
You Pay: All charges