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Blue Cross Blue Shield of Maryland Traditional Dental
(Click here for rates,
effective 1/1/2003 to 12/31/2003.)
Open
enrollment December for a January effective date
UNLESS
You are a
new member of MAR
OR
There has been a qualified change in family status.
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 |
Class |
Plan Pays |
Benefits |
I
Diagnostic/
Preventative |
100 % of
Allowed Benefit |
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 |
50 % 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.
General Limitations
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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.
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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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