| |
BlueSelect® Dental |
BlueCare Dental |
| Selection of Dentists |
Each subscriber chooses a dentist from a broad list of participating dentists statewide. |
Each subscriber chooses a dentist from a broad list of participating dentists statewide. |
| Deductible |
$50 deductible. |
Deductible plan options range from $25 to $75 for Individual in-network services. |
| Maximum Benefit |
Annual maximum benefit of $1,000 (Options 1A, 2 and 3) or $1,250 (Option 4) on primary and major services. |
Annual maximum benefit options range from $750 to $2,000 for Individual
in-network services on primary and major services. |
Diagnostic
and Preventive Services |
Routine cleanings, x-rays, oral exams, children's fluoride applications, space maintainers and sealants covered at 100% of maximum reimbursement allowance with in-network dentists; 80% of maximum reimbursement allowance with out-of-network dentists. |
Routine cleanings, x-rays, oral exams, children's fluoride applications, space maintainers and sealant coverage options range from 80% to 100% of maximum reimbursement allowance for Individual in-network services. |
| Primary Services (maintenance, oral surgery and periodontic services). |
Paid at 80% of the pre-negotiated price when using LINCS Dental Connection network dentists. Paid at 60% of the pre-negotiated price when using non-network dentists. |
Coverage options include Primary Services ranges from 50% to 90% of the
in-network pre-negotiated price. |
| Major Services (inlays, crowns, veneers, dentures, partials and bridges) |
Paid at 50% of the pre-negotiated price when using LINCS Dental Connection network dentists. Paid at 30% of the pre-negotiated price when using non-network dentists.
|
Coverage options include Major Services ranges from 50% to 60% of the
in-network pre-negotiated price. |
| Orthodontics (Available to groups with 50 or more enrolled employees.) |
Optional: Available only to eligible dependents to age 19. Paid at 50% of the pre-negotiated price when using network dentists. Paid at 30% of the pre-negotiated price when using non-network dentists. Subject to $1,000 lifetime maximum benefit.
(Options 2, 3 and 4 only.) |
Coverage for Orthodontia for adults and children is available depending upon the product selected and plan design. If plan design includes Orthodontia coverage, services will be paid at 50% of the in-network pre-negotiated prices subject to a lifetime maximum with benefit ranges from $1,000 to $2,000
in-network. |
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