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Plan 65 - Dental

This optional program is only available to you at the time you enroll in your health program. Coverage may not be added at a later date.

These benefits are covered at 100 percent of the allowable charge:

• Oral examinations - two per year
• Prophylaxis, including cleaning, scaling and polishing - two per year
• Dental x-rays required to treat or diagnose diseases or abnormalities of the teeth, surrounding tissue and cavity detection (limited to two bitewing x-rays per year and one full mouth x-ray during a five-year period)

These benefits are covered at 80 percent of the allowable charge, following a $50 annual deductible, to an annual maximum benefit payment of $1,000 each calendar year:

• Simple extractions
• Fillings (except gold)
• Root canal treatment
• Periodontic treatment of the gums, consisting of examination, management and surgery
• Extraction of impacted teeth
• Repair of dentures
• General anesthesia when the dental treatment is a covered service

 

Dental plan services NOT covered

• Any dental service or procedure relating to the teeth, gums, or structures supporting the teeth or providing for proper occlusion of the teeth not listed in this dental care program
• Patient education services; hospital calls and consultations
• Laboratory and pathological examinations; occlusal adjustments
• Dental implant services
• Services for diseases or injuries caused by or arising out of acts of war or aggression
• Services for cosmetic purposes except for accidental injury
• Services related to alveolar ridge augmentations
• Temporomandibular joint dysfunction syndrome services
• Orthodontic services
• Crowns, onlays, and oral surgery
• Dentures (full or partial) and bridges (fixed or removable)
  

Please note: With this optional dental program, you will need to use a Blue Cross and Blue Shield of Kansas contracting dentist to receive maximum benefits.

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