Elite 10020010001500Effective 712018 - PDF document

1 Elite + 100/200/1000/1500Effective 7-1-2
Elite + 100/200/1000/1500Effective 7-1-2018 29379292 • FI FI POD 7-18 Elite + 100/200/1000/1500Effective 7-1-2018 29379292 • FI FI POD 7-18 BlueDental Elite + BlueDental Elite + Deductible Amount $100 per member per benet period, $200 per family per benet period Claims for covered services incurred October 1 through December 31 include a deductible carry-over to the next year. Annual Maximum $1,000 per member per benet period Orthodontic Services and Maximum Covered at 50% of allowed charge. Deductible does not apply. $1,500 lifetime maximum per member. Covered at 100% of allowed charge. Deductible does not apply. Oral Evaluations, two per calendar year Prophylaxis, four per calendar year. One additional for members under the care of a medical professional during pregnancy. Full-mouth x-rays, once every ve years Panoramic lm, once every ve years Intraoral lms: • Periapical – four per calendar year per dentist if not performed in conjunction with denitive procedures • Occlusal – two per two calendar years under age eight Bitewing x-rays, once per calendar year Topical uoride application, twice per calendar year Emergency palliative treatment and emergency oral evaluations Covered at 80% of allowed charge, after the deductible is met. Sealants, one per tooth per three year period for members through age 18 Fillings consisting of silver amalgam, silicate and plastic restorations Simple extractions, surgical extractions and impactions Pulpal therapy Root canal re-treatment, one per tooth per lifetime Periodontal Services: • Full mouth debridement – one per member per lifetime • Periodontal maintenance following active periodontal therapy – four per calendar year including routine prophylaxis • Periodontal scaling and root planing – one per 36 months per area of the mouth • Surgical periodontal procedures – one per 36 months per area of the mouth • Guided tissue regeneration – one per tooth per lifetime • Gingival curettage • Gingivectomy and gingivoplasty • Osseous surgery • Mucogingivoplastic surgery General anesthesia and IV sedation - a total of 60 minutes per session Covered at 50% of allowed charge, after the deductible is met. Denture relining, rebasing or adjustments are considered part of the denture charges if provided within six months of insertion by the same dentist. Single crowns, inlays, onlays - not within ve years of previous placement Replacement of natural tooth/teeth in an arch, not within ve years of a xed partial denture, full denture or partial removable denture Relining of immediate dentures, after six months of insertion Relining of full and partial dentures, once every three years Bridges, replacement of lost or defective bridges, once every ve years Oral maxillofacial surgery including: fracture and dislocation treatment, cyst and abscess diagnosis and treatment Occlusal guards for treatment of bruxism, once every three years Eligible children include children under age 26. Coverage will be continued until the end of the month in which the child becomes age 26. Eligible children also include children placed with the employee or covered spouse for adoption or whom the employee or covered spouse have legally adopted; children for whom the employee or covered spouse have been appointed legal guardian by court order; children for whom the employee or covered spouse are required by court order to provide dental benets; or children incapable of self-support because of an intellectual disability or a physical handicap that began before they reached 26 years of age and who are primarily dependent on the employee or covered spouse. Employees grandchildren or grandchildren of covered spouse are also eligible if the parent of the grandchild is unmarried; the parent of the grandchild is a covered eligible dependent; and the parent is primarily dependent on the employee for their support. To qualify for a group dental plan, the employer must contribute a minimum of 75% toward the single premium payment. This chart presents a brief explanation of the covered services and payment levels of this product. It should not be used to determine whether your dental expenses will be paid. The may be continued, see your Sales & Account Executive or write to Blue Cross Blue Shield of North Dakota. This information is available to individuals with disabilities in alternate formats, free of charge, by calling Member Services at 1-800-342-4718 (toll-free) or through the North Dakota Relay at 1-800-366-6888 or 711. Deductible Amount $100 per member per benet period, $200 per family per benet period Claims for covered services incurred October 1 through December 31 include a deductible carry-over to the next year. Annual Maximum $1,000 per member per benet period Orthodontic Services and Maximum Covered at 50% of allowed charge. Deductible does not apply. $1,500 lifetime maximum per member. Covered at 100% of allowed charge. Deductible does not apply. Oral Evaluations, two per calendar year Prophylaxis, four per calendar year. One additional for members under the care of a medical professional during pregnancy. Full-mouth x-rays, once every ve years Panoramic lm, once every ve years Intraoral lms: • Periapical – four per calendar year per dentist if not performed in conjunction with denitive procedures • Occlusal – two per two calendar years under age eight Bitewing x-rays, once per calendar year Topical uoride application, twice per calendar year Emergency palliative treatment and emergency oral evaluations Covered at 80% of allowed charge, after the deductible is met. Sealants, one per tooth per three year period for members through age 18 Fillings consisting of silver amalgam, silicate and plastic restorations Simple extractions, surgical extractions and impactions Pulpal therapy Root canal re-treatment, one per tooth per lifetime Space maintainers, one per ve years for members through age 13 Periodontal Services: • Full mouth debridement – one per member per lifetime • Periodontal maintenance following active periodontal therapy – four per calendar year including routine prophylaxis • • Surgical periodontal procedures – one per 36 months per area of the mouth • Guided tissue regeneration – one per tooth per lifetime • Gingival curettage • Gingivectomy and gingivoplasty • Osseous surgery • Mucogingivoplastic surgery General anesthesia and IV sedation - a total of 60 minutes per session Covered at 50% of allowed charge, after the deductible is met. Denture relining, rebasing or adjustments are considered part of the denture charges if provided within six months of insertion by the same dentist. Single crowns, inlays, onlays - not within ve years of previous placement Veneers, other than cosmetic, once every ve years Replacement of natural tooth/teeth in an arch, not within ve years of a xed partial denture, full denture or partial removable denture Relining of immediate dentures, after six months of insertion Relining of full and partial dentures, once every three years Bridges, replacement of lost or defective bridges, once every ve years Oral maxillofacial surgery including: fracture and dislocation treatment, cyst and abscess diagnosis and treatment Occlusal guards for treatment of bruxism, once every three years Eligible children include children under age 26. Coverage will be continued until the end of the month in which the child becomes age 26. Eligible children also include children placed with the employee or covered spouse for adoption or whom the employee or covered spouse have legally adopted; children for whom the employee or covered spouse have been appointed legal guardian by court order; children for whom the employee or covered spouse are required by court order to provide dental benets; or children incapable of self-support because of an intellectual disability or a physical handicap that began before they reached 26 years of age and who are primarily dependent on the employee or covered spouse. Employees grandchildren or grandchildren of covered spouse are also eligible if the parent of the grandchild is unmarried; the parent of the grandchild is a covered eligible dependent; and the parent is primarily dependent on the employee for their support. To qualify for a group dental plan, the employer must contribute a minimum of 75% toward the single premium payment. This chart presents a brief explanation of the covered services and payment levels of this product. It should not be used to determine whether your dental expenses will be paid. The written benet plan governs the benets available. For further details of the coverage, including exclusions, any reductions or limitations and the terms under which the benet plan may be continued, see your Sales & Account Executive or write to Blue Cross Blue Shield of North Dakota. This information is available to individuals with disabilities in alternate formats, free of charge, by calling Member Services at 1-800-342-4718 (toll-free) or through the North Dakota Relay at 1-800-366-6888 or 711.