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Blue Cross Blue Shield of Maryland Traditional Dental
(Click here for rates,
effective 1/1/2005 to 12/31/2005.)
Open
enrollment December for a January effective date.
The Traditional Dental
Plan does not require that you visit a network dentist, though benefits are
based on the CareFirst Allowed Benefit percentages and are the same whether
or not you see a provider in the network. Approximately 84% of the
dentists in the state of Maryland are BCBS participating dentists.
| Annual Deductibles and
Maximums |
| Calendar Year
Deductible applies to Class II, III, and IV only. |
$50
Individual
$150 Family |
| Annual Benefit
Maximum applies to Class I, II, II, & IV |
$1,000 Combined |
| Lifetime Maximum,
Class V to age 19 or 23 (if full time student) |
$800
Combined |
Class |
Coinsurance |
Benefits |
I
Diagnostic/
Preventative |
No
charge if from 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.
Prophylaxix (two teeth
cleanings per period).
Space maintainers, limited
to once in any 5-year period.
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II
Basic Services |
80%
of Allowed Benefit after deductible. ** |
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Fillings of silver amalgam,
plastic, or equivalent materials.
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Simple extractions.
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Root planing.
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Periodontal services, limited
to once in any two year period.
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Osseous surgery, limited to
once in any five-year period.
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III
Surgical |
50% of
Allowed Benefit after deductible. ** |
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IV
Restorative |
50% of
Allowed Benefit after deductible. ** (when applicable) |
Inlasy and crowns that are
not part of a bridge.
Dentures - full and
partial (once per 60 months).
Denture adjustments and
relining.
Fixed bridges, including
abutment work (once every 60 months).
Repair of prosthetic
appliances.
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V
Orthodontic Services |
50% of
Allowed Benefit after deductible. ** |
Diagnosis, including
models, x-rays, and photographs.
Orthodontic appliances
(braces).
Active treatment,
including banding.
Subsequent retention
treatment.
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** NOTE: CareFirst and CareFirst BlueChoice
payments are based on theCareFirst and CareFirst BlueChoice Allowed
Benefit. Participating dentists accept 100% of Allowed Benefit
as payment in full for covered services. Non-participating
dentists may bill the member the difference between the Allowed
Benefit and their charges.
Not all services and procedures
are covered by your benefits contracts. This plan summary is
for comparison purposes only, and does not create rights not given
through the benefit plan.
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