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Dental Blue
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Available benefits

Your dental benefits provide coverage for diagnostic and preventive care, as well as, basic services and major services. Plus, you may obtain services from any licensed dentist. The chart below describes how your dental plan works:

Type of Coverage Plan Benefits
Preventive Services
Routine oral exams
Adult & child cleaning
Bitewing x–rays
Pulp testing
Annual fluoride cleaning (members through 18–years–old only)
Palliative emergency treatment & emergency oral examinations
Other diagnostic & preventive services
Sealants (members 5-15 years old only)

 You pay nothing for two checkups and cleanings per benefit period (with no deductible and no waiting period).1
Basic Services
Routine fillings
Space maintainers (members under 16–years–old)
Endodontics
Simple extractions
Stainless Steel Crowns
Oral surgery
Other basic services

 You pay 40% after dental deductible is met (6 month waiting period).1
Major Services
Gingival curettage
Gingivectomy and gingivoplasty
Periodontal maintenance
Inlays and onlays (once per 5 years)
Porcelain Crowns
Dentures
Bridges
Other major services

 You pay 50% after dental deductible is met (12 month waiting period).1
Deductible, basic and major services $75
Annual maximum, all services $1,0002

Waiting periods
Diagnostic & Preventive Services

None
Basic Services 6 months
Major Services 12 months
Dental Blue for Individuals Limitations and Exclusions
Like most health care plans, Dental Blue for Individuals has some limitations and exclusions.

Your Next Steps

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1 Based on allowed amount, as determined by BCBSNC. The allowed amount may be substantially less than the provider’s actual charge. You will be responsible for the charges above the allowed amount, in addition to any deductible and coinsurance applied.

2 Annual maximum on all services is $1,000 (includes diagnostic and preventive, basic and major services).

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