2023 Blue Cross and Blue Shield Service Benefit Plan - Standard and Basic Option
Section 5(g). Dental Benefits
Page 124
Section 5(g). Dental Benefits
Page 124
Basic Option Dental Benefits
Under Basic Option, we provide benefits for the services listed below. You pay a $30 copayment for each evaluation, and we pay any balances up to the Maximum Allowable Charge (MAC; see page 122). This is a complete list of dental services covered under this benefit for Basic Option. You must use a Preferred dentist in order to receive benefits. For a list of Preferred dentists, visit www.fepblue.org/provider to use our National Doctor & Hospital Finder, or call us at the customer service phone number on the back of your ID card.
Under Basic Option, we provide benefits for the services listed below. You pay a $30 copayment for each evaluation, and we pay any balances up to the Maximum Allowable Charge (MAC; see page 122). This is a complete list of dental services covered under this benefit for Basic Option. You must use a Preferred dentist in order to receive benefits. For a list of Preferred dentists, visit www.fepblue.org/provider to use our National Doctor & Hospital Finder, or call us at the customer service phone number on the back of your ID card.
Basic Option Dental Benefits
Clinical oral evaluations
Covered Service
Periodic oral evaluation*
We Pay
Preferred: All charges in excess of your $30 copayment
Participating/Non-participating: Nothing
You Pay
Preferred: $30 copayment per evaluation
Participating/Non-participating: You pay all charges
Covered Service
Limited oral evaluation
We Pay
Preferred: All charges in excess of your $30 copayment
Participating/Non-participating: Nothing
You Pay
Preferred: $30 copayment per evaluation
Participating/Non-participating: You pay all charges
Covered Service
Comprehensive oral evaluation*
We Pay
Preferred: All charges in excess of your $30 copayment
Participating/Non-participating: Nothing
You Pay
Preferred: $30 copayment per evaluation
Participating/Non-participating: You pay all charges
*Benefits are limited to a combined total of 2 evaluations per person per calendar year.
Clinical oral evaluations
Covered Service
Periodic oral evaluation*
We Pay
Preferred: All charges in excess of your $30 copayment
Participating/Non-participating: Nothing
You Pay
Preferred: $30 copayment per evaluation
Participating/Non-participating: You pay all charges
Covered Service
Limited oral evaluation
We Pay
Preferred: All charges in excess of your $30 copayment
Participating/Non-participating: Nothing
You Pay
Preferred: $30 copayment per evaluation
Participating/Non-participating: You pay all charges
Covered Service
Comprehensive oral evaluation*
We Pay
Preferred: All charges in excess of your $30 copayment
Participating/Non-participating: Nothing
You Pay
Preferred: $30 copayment per evaluation
Participating/Non-participating: You pay all charges
*Benefits are limited to a combined total of 2 evaluations per person per calendar year.
Basic Option Dental Benefits
Diagnostic imaging
Covered Service
Intraoral – complete series including bitewings (limited to 1 complete series every 3 years)
We Pay
Preferred: All charges in excess of your $30 copayment
Participating/Non-participating: Nothing
You Pay
Preferred: $30 copayment per evaluation
Participating/Non-participating: You pay all charges
Diagnostic imaging
Covered Service
Intraoral – complete series including bitewings (limited to 1 complete series every 3 years)
We Pay
Preferred: All charges in excess of your $30 copayment
Participating/Non-participating: Nothing
You Pay
Preferred: $30 copayment per evaluation
Participating/Non-participating: You pay all charges
Basic Option Dental Benefits
Preventive
Covered Service
Prophylaxis – adult (up to 2 per calendar year)
We Pay
Preferred: All charges in excess of your $30 copayment
Participating/Non-participating: Nothing
You Pay
Preferred: $30 copayment per evaluation
Participating/Non-participating: You pay all charges
Covered Service
Prophylaxis – child (up to 2 per calendar year)
We Pay
Preferred: All charges in excess of your $30 copayment
Participating/Non-participating: Nothing
You Pay
Preferred: $30 copayment per evaluation
Participating/Non-participating: You pay all charges
Covered Service
Topical application of fluoride or fluoride varnish – for children only (up to 2 per calendar year)
We Pay
Preferred: All charges in excess of your $30 copayment
Participating/Non-participating: Nothing
You Pay
Preferred: $30 copayment per evaluation
Participating/Non-participating: You pay all charges
Covered Service
Sealant – per tooth, first and second molars only (once per tooth for children up to age 16 only)
We Pay
Preferred: All charges in excess of your $30 copayment
Participating/Non-participating: Nothing
You Pay
Preferred: $30 copayment per evaluation
Participating/Non-participating: You pay all charges
Preventive
Covered Service
Prophylaxis – adult (up to 2 per calendar year)
We Pay
Preferred: All charges in excess of your $30 copayment
Participating/Non-participating: Nothing
You Pay
Preferred: $30 copayment per evaluation
Participating/Non-participating: You pay all charges
Covered Service
Prophylaxis – child (up to 2 per calendar year)
We Pay
Preferred: All charges in excess of your $30 copayment
Participating/Non-participating: Nothing
You Pay
Preferred: $30 copayment per evaluation
Participating/Non-participating: You pay all charges
Covered Service
Topical application of fluoride or fluoride varnish – for children only (up to 2 per calendar year)
We Pay
Preferred: All charges in excess of your $30 copayment
Participating/Non-participating: Nothing
You Pay
Preferred: $30 copayment per evaluation
Participating/Non-participating: You pay all charges
Covered Service
Sealant – per tooth, first and second molars only (once per tooth for children up to age 16 only)
We Pay
Preferred: All charges in excess of your $30 copayment
Participating/Non-participating: Nothing
You Pay
Preferred: $30 copayment per evaluation
Participating/Non-participating: You pay all charges
Basic Option Dental Benefits
Covered Service
Not covered: Any service not specifically listed above
We Pay
Nothing
You Pay
All charges
Covered Service
Not covered: Any service not specifically listed above
We Pay
Nothing
You Pay
All charges