| |
Standard plan |
Complete plan |
Enhanced plan |
Preventive (100%):
No waiting period |
Routine exams and cleaning (1 per benefit period)
Bitewing X-rays (1 per benefit period)
Fluoride treatment for members under 19 only (1 per benefit period)
Emergency treatment for pain Sealants for children ages 5-15 |
Routine exams and cleaning (2 per benefit period)
Bitewing X-rays (1 per benefit period)
Fluoride treatment for members under 19 only (1 per benefit period)
Emergency treatment for pain Sealants for children ages 5-15
|
Routine exams and cleaning (2 per benefit period)
Bitewing X-rays (1 per benefit period)
Fluoride treatment for members under 19 only (1 per benefit period)
Emergency treatment for pain Sealants for children ages 5-15 |
Basic services (80%):
Six-month waiting period for Standard plan;
No waiting period for Enhanced plan |
Simple restorative services (fillings)
Simple tooth removal |
Simple restorative services (fillings)
Simple tooth removal
|
Simple restorative services (fillings)
Simple tooth removal
X-rays of the roots of teeth
X-rays (full mouth or panorex - 1 per 36 months)
Endodontics (includes root canals)
Periodontics |
Major services (50%):
12-month waiting period for all plans |
Endodontics (including root canal)
Periodontics
Surgical tooth removal and oral surgery
Medically appropriate anesthesia
Space maintainers
X-rays of the roots of teeth
X-rays (full mouth or panorex - 1 per 36 months) |
X-rays of the roots of teeth
X-rays (full mouth or panorex - 1 per 36 months)
Endodontics (includes root canals)
Periodontics
Surgical tooth removal and oral surgery
Medically appropriate anesthesia
Space maintainers
Major restorative services (crowns/inlays)
Prosthodontics (bridges/dentures)
Denture relines (over 6 months old)
Recementation and repair of crowns, inlays, bridges, dentures
|
Surgical tooth removal and oral surgery
Medically appropriate anesthesia
Space maintainers
Major restorative services (crowns/inlays)
Dental implants
Prosthodontics (bridges/dentures)
Denture relines (over 6 months old)
Recementation and repair of crowns, inlays, bridges, dentures |
Orthodontia
12-month waiting period, if applicable |
Not available |
Available as an option.
Children under age 19
No deductible
50% coverage
$1,000 or $1,500 lifetime maximum*
|
Available as an option.
Children under age 19
No deductible
50% coverage
$1,000 or $1,500 lifetime maximum* |
| Lifetime deductible |
$100 |
$100 |
$100 (except Orthodontia) |
| Annual maximum |
$1,000 (all services combined) |
$1,000 or $1,500 (all services combined, except orthodontia) |
$1,000 or $1,500 (all services combined, except orthodontia) |
| Prior coverage credit (takeover) |
Not available |
Yes |
Yes |
| Add/Termination dates |
First of the month |
First of the month |
First of the month |
* Orthodontia lifetime maximum must match selected benefit period maximum.
Like most health care plans, Dental Blue Select has some limitations and exclusions.
