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Blue Cross Dental PPO

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PPO Enrollment Application

 

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
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.
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Copyright 2005 Oleg Skurskiy Authorized Independent Agent, CA License 0E50389