Blue Cross Dental with
Free Choice of Dentist - PPO
Plan
Open to all living in CA
|
|
|
|
Annual Maximum Benefit |
|
Participating provider |
$1,000 per person per calendar year; benefits listed
are after the deductible and applicable waiting
periods
are satisfied |
|
Non-participating provider |
$1,000 per person per calendar year; benefits listed
are after the deductible and applicable waiting
periods
are satisfied |
|
Major Restorative Services |
|
Participating provider |
Oral surgery (extractions): All charges except $49 per single tooth, $46 each additional tooth, 3-month
waiting period |
|
Non-participating provider |
Oral surgery (extractions): All charges except $49 per single tooth, $46 each additional tooth, 3-month
waiting period |
|
Endodontics |
|
Participating provider |
Root canal therapy: All charges except $154-$242, depending on tooth, excluding final restoration,
12-month
waiting period |
|
Non-participating provider |
Root canal therapy: All charges except $154-$242, depending on tooth, excluding final restoration,
12-month
waiting period |
|
Periodontics |
|
Participating provider |
Gingivectomy: All charges except $145 per quadrant; Osseous surgery: All charges except $277 per quadrant;
12-month waiting period for all services |
|
Non-participating provider |
Gingivectomy: All charges except $145 per quadrant; Osseous surgery: All charges except $277 per quadrant;
12-month waiting period for all services |
|
Prosthodontics |
|
Participating provider |
Pontic: All charges except $264; Post and Core: All charges except $75; Complete denture: All
charges
except $343; Partial denture: All charges except $308; Denture reline (chairside): All charges except $75; Denture reline
(lab): All charges except $106 |
|
Non-participating provider |
Pontic: All charges except $264; Post and Core: All charges except $75; Complete denture: All
charges
except $343; Partial denture: All charges except $308; Denture reline (chairside): All charges except $75; Denture reline
(lab): All charges except $106 |
|
Orthodontic Services |
|
Participating provider |
Not covered |
|
Non-participating provider |
Not covered |
|
Annual Deductible |
|
Participating provider |
$50 per person, limited to three deductibles
per family |
|
Access to Providers |
|
Participating provider |
Dentist of your choice3 |
|
Non-participating provider |
Dentist of your choice3 |
|
Annual Deductible |
|
Non-participating provider |
$50 per person, limited to three deductibles
per family |
|
Preventive Services |
|
Participating provider |
No charge |
|
Non-participating provider |
Office visits: All charges except $25; Cleaning: All charges except $39/adult, $30/child up to two times
in 12 consecutive months; Fluoride application (child only): All charges except $14 up to twice per year |
|
Diagnostic Services |
|
Participating provider |
No charge |
|
Non-participating provider |
Oral exams: All charges except $25; x-rays (full-mouth): All charges except $60, limited to once every
3 years |
|
Minor Restorative Services |
|
Participating provider (are
limited consider the DHMO if using a panel dds) |
Fillings: All charges except $38-$84, depending on tooth
and number of surfaces, 3-month waiting period;
Crowns (stainless steel): All charges except $57, 12-month waiting period |
|
Non-participating provider |
Fillings: All charges except $38-$84, depending on tooth
and number of surfaces, 3-month waiting period;
Crowns (stainless steel): All charges except $57, 12-month waiting period |
2. Although
the benefit schedule is the same for both Participating and Non-Participating Dentists, you may have a greater share of the costs for your care if you choose a Non-Participating Dentist.
3. Although
you are free to select a Dentist of your choice, your benefits are higher when you choose a Participating Dentist.
4. Dollar amounts
reflect maximum payment by Blue Cross. The Plan pays specific amounts or amounts billed by your dentist, whichever is less.
.a
subscriber needs to be: age 64-3/4 Or younger,
. a permanent legal resident of California, and a U.S. resident
for at least the last 3 months
Contract Type
Area
1 Area 2 Area 3
Area 4 Area 5 Area 6 Area 7 Area 8 Area 9
Subscriber
$ 37
34 35
39 41
39 35
38 41
S & Spouse
73
66 67
76 79
76 68
34 80
S & Child
58
53 54 61
64 61
54 59
64
S & Children
89
82 83
94 99
94 84
91 99
Family
112 103 106
121 126
121 107
116 126
1 Child
30 28 28
32 33
32 28
31 33
2 Children
58 53 53
61 63
61 54
59 63
3+ Children
81 75 76
86 90
86 77
84 90
County Rating Areas
Area 1: Del Norte,
Lassen, Modoc, Monterey, Plumas Shasta Sierra Siskiyou, Tehama, Trinity
Area 2: Alpine, Amador, Calaveras, El Dorado, Fresno, Inyo,
Madera, Marin, Mariposa, Merced, Mono, Nevada, Placer, Sacramento, San Benito, San Joaquin, San Mateo, Santa Clara (except
ZIP code 94303) Stanislaus, Tuolumne
Area 3: Alameda,
Butte, Colusa, Contra Costa, Glenn, Humboldt, Lake, Mendocino, Napa, San Francisco, Santa Clara (except ZIP code 94303) Santa
Cruz, Solano, Sonoma, Sutter, Yolo, Yuba
Area 4: Orange, Riverside
(except ZIP code 92883)
Area 5: Los Angeles
(except ZIP codes beginning with 906-12,915,917,918,935)
Area 6: Imperial,
Riverside (except ZIP code 92883)
Area 7: Kern, Kings,
Tulare
Area 8: San Luis Obispo,
Santa Barbara, Ventura (except ZIP codes beginning with 913)
Area 9: Los Angeles
(ZIP codes beginning with 906-912,915,917,918,& 935)
Non-network counties by rating
areas. If this Policy is sold in any of the following areas, review the Statement
of Understanding on the application.
Area 1: Plumas,
Sierra, Trinity
Area 2: Alpine,
Calaveras, Inyo, Mariposa, Mono, Tuolumne
Area 3: Colusa,
Glenn, Lake, Yolo
Return Your Application by Mail to:
Include your check made payable to Blue
Cross
American Marketing Administrators, Inc.
23901 Calabasas Road Suite 2014
Calabasas, CA 91302-3307
