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CareFirst BlueChoice
Traditional Dental Coverage
(Click
here for rates effective 1/1/2005 to 12/31/2005)
Open enrollment
December for a January 1st effective date.
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Calendar Year Deductible
Applies to Class II, III and IV only |
$ 50 Individual
$ 150 Family |
Annual Benefit Maximum
Applies to Class II, III and IV only |
$ 1,000 Combined |
Lifetime Maximum (to age 19)
Orthodontics, Class IV |
$ 800 Combined |
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Class |
Plan Pays |
Benefits |
I
Diagnostic/
Preventative |
100 % of
Allowed Benefit
(If Participating
Dentist) |
Oral examination. routine
cleaning, bitewing x-rays, limited to twice in a calendar year period.
X-Rays, including crowns and
roots, limited to once in any thirty-six month period
Topical fluoride application for
members age 19 or younger, limited to twice in a calendar year period
Emergency treatment
Space maintainers, limited to once
in any five-year-period
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II
Surgical
Restorative
Periodontal |
80 % of
Allowed Benefit |
Fillings of silver amalgam,
plastic, or equivalent materials
Simple extractions
Root tip removal and root canal
treatment
Pulp removed and pulp capping
Root canal
Root resection
Surgical extractions
Oral surgical services
General anesthesia for oral
surgery
Periodontal services, limited to
once in any two-year-period
Osseous surgery, limited to once
in any five- year-period
Gingivectomy, limited to once in
any five- year-period
Periodontal procedures require
pre-treatment plan
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III
Prosthetics |
50 % of
Allowed Benefit |
Inlays and crowns that are not
part of a bridge
Dentures - full and partial
Fixed bridges, including abutment
work
Repair of prosthetic appliances
Class III procedures require
pre-treatment plan and are limited to once in any five-year- period.
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IV
Orthodontics |
50 % of
Allowed Benefit |
Diagnosis, including models,
x-rays and photographs
Orthodontic appliances (braces)
Active treatment, including
banding
Subsequent retention treatment
Class IV procedures require
pre-treatment plan
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General
Exclusions
This plan does not cover:
- Appliances or restorations needed in complete reconstruction where
natural teeth are present to increase vertical dimension.
- Treatment for services for temporomandibular joint (TMJ) dysfunction not
caused by documented disease, physical trauma, injury or congenital deformity.
- Gold foil fillings.
- Implants.
- Intravenous (IV) sedation.
- Sealants.
- Dental services in connection with birth defects or mainly for cosmetic
reasons Exceptions include cleft lip and palate if you have surgical/medical benefits
and/or major medical benefits; and surgery to correct defects to whole sound natural teeth
and you receive through a trauma after this coverage began.
- Periodontal appliances.
- Prescription drugs.
- Splinting.
- Niteguards.
- The replacement of any denture, bridge or crown that is needed because of
the item's loss or theft or when the existing denture, bridge or crown is satisfactory or
could be repaired to be satisfactory.
- The repair or replacement of any orthodontic appliance.
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General Limitations
- You and your
provider have twelve months from the date of service to submit a claim. For example,
if the date you received services was July 12, you have until July 12 of the next year to
submit your claim. If you fail to submit your claim in this timeframe, BCBS will not
make any payment.
- No coverage is
provided for services and supplies for the treatment of any injury, illness or medical
condition that is not medically necessary.
- No coverage is
provided for services and supplies for the treatment of illness resulting from an act of
war or relating to a felony.
- No coverage is
provided for services and supplies for cosmetic surgery, or for a medical condition or
complication arising from cosmetic surgery.
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© 2002 Benefit Choices Inc. |
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