BlueSelect Dental
Dental Plan
| Benefit Highlight | BlueSelect Dental Covered Services | |
|---|---|---|
| Option 1 — Basic | Option 2 — Enhanced | |
| Preventive Procedures 100% covered In-network services |
Oral examinations, cleaning, scaling and polishing, bitewing X-rays, full mouth X-rays, fluoride application for children under 19, space maintainers for children under 19, sealants for children under 14 | |
| Coinsurance | You pay 0% for covered services | You pay 0% for covered services |
| Restorative Procedures 80% covered In-network services $50 deductible Six-month waiting period |
Fillings (except gold), simple extractions, root canal treatment, extraction of impacted teeth, periodontic treatment of the gums, repair of dentures, IV sedation or general anesthesia | |
| Not covered | Re-cementing of crowns, inlays and bridges, stainless steel crowns, surgical removal of teeth, diagnosis and treatment of gum disease | |
| Coinsurance | You pay 20% for covered services | You pay 20% for covered services |
| Complex Restorative Procedures 50% covered In-network services $200 deductible 12-month waiting period |
Not covered | Inlays, onlays and crowns, veneers or similar properties of crowns and bridges placed on or replacing the 10 upper and lower front teeth, dentures and bridges, denture adjustments, relining and rebasing, fixed bridge repairs |
| Coinsurance | Not covered | You pay 50% for covered services |
| Annual Maximum Benefit | $1,000 | $1,000 |
