2023 Blue Cross and Blue Shield Service Benefit Plan - Standard and Basic Option
Section 5. Benefits
Section 5(g). Dental Benefits
Dental Benefits
Section 5. Benefits
Section 5(g). Dental Benefits
Dental Benefits
Dental Benefits
What is Covered
Standard Option dental benefits are presented in the chart on the following page.
Basic Option dental benefits appear on page 124 .
Note: See Section 5(b) for our benefits for Oral and maxillofacial surgery, and Section 5(c) for our benefits for hospital services (inpatient/outpatient) in connection with dental services, available under both Standard Option and Basic Option.
Preferred Dental Network
All Local Plans contract with Preferred dentists who are available in most areas. Preferred dentists agree to accept a negotiated, discounted amount called the Maximum Allowable Charge (MAC) as payment in full for the following services. They will also file your dental claims for you. Under Standard Option, you are responsible, as an out-of-pocket expense, for the difference between the amount specified in this Schedule of Dental Allowances and the MAC. To find a Preferred dentist near you, 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. You can also call us to obtain a copy of the applicable MAC listing.
Note: Dentists and oral surgeons who are in our Preferred Dental Network for routine dental care are not necessarily Preferred providers for other services covered by this Plan under other benefit provisions (such as the surgical benefit for oral and maxillofacial surgery). Call us at the customer service phone number on the back of your ID card to verify that your provider is Preferred for the type of care (e.g., routine dental care or oral surgery) you are scheduled to receive.
What is Covered
Standard Option dental benefits are presented in the chart on the following page.
Basic Option dental benefits appear on page 124 .
Note: See Section 5(b) for our benefits for Oral and maxillofacial surgery, and Section 5(c) for our benefits for hospital services (inpatient/outpatient) in connection with dental services, available under both Standard Option and Basic Option.
Preferred Dental Network
All Local Plans contract with Preferred dentists who are available in most areas. Preferred dentists agree to accept a negotiated, discounted amount called the Maximum Allowable Charge (MAC) as payment in full for the following services. They will also file your dental claims for you. Under Standard Option, you are responsible, as an out-of-pocket expense, for the difference between the amount specified in this Schedule of Dental Allowances and the MAC. To find a Preferred dentist near you, 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. You can also call us to obtain a copy of the applicable MAC listing.
Note: Dentists and oral surgeons who are in our Preferred Dental Network for routine dental care are not necessarily Preferred providers for other services covered by this Plan under other benefit provisions (such as the surgical benefit for oral and maxillofacial surgery). Call us at the customer service phone number on the back of your ID card to verify that your provider is Preferred for the type of care (e.g., routine dental care or oral surgery) you are scheduled to receive.
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
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