Plan 65 - BlueCare DentalPlus Benefit Details and Exclusions

Features of this program include:

  • $1,500 annual maximum
  • 12 month waiting period on major services
  • $50 annual deductible per Insured (combined deductible applies to Primary and Major services)
    100% for preventive services (Accumulates to annual maximum)
  • Major services with 50/50 coinsurance (Accumulates to annual maximum)
  • Primary services with 80/20 coinsurance (Accumulates to annual maximum)
  • $200 annual maximum for whitening services and supplies provided by dentist (100% accumulates to annual maximum)


These Preventive Services are covered at 100 percent of the allowable charge (accumulates to annual $1,500 maximum):

  • 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 (includes two bitewings per year, and one full-mouth during a five-year period)

These Primary Services benefits are covered at 80 percent of the allowable charge, following a $50 annual deductible (combined deductible applies to Primary and Major services), to an annual maximum benefit payment of $1,500 each calendar year:

  • Simple extractions
  • Fillings (except gold)
  • Root canal treatment
  • Endodontics
  • Periodontic treatment of the gums, consisting of examination, management and surgery
  • Extraction of impacted teeth
  • Inlays
  • Repair of dentures
  • General anesthesia when the dental treatment is a covered service
  • Emergency treatment to temporarily relieve acute dental pain (subject to limitations)
  • Non-surgical care of acute oral infection and oral lesions

 

These Major Services benefits are covered at 50 percent of the allowable charge, following a $50 annual deductible (combined deductible applies to Primary and Major services), to an annual maximum benefit payment of $1,500 each calendar year:

  • Crowns
  • Onlays
  • Dentures
  • Bridges
  • Oral/Periodontal Surgery (Other than Periodontal surgery of the gums)
  • Dental Implants

 

Dental plan services NOT covered:

  • Any dental service not listed as a covered service in this program
  • Patient education services, hospital calls and/or consultations
  • Laboratory and pathological examinations
  • Bone grafts for alveolar ridge augmentation
  • Dental services primarily for cosmetic purposes, except for an accidental injury
  • All Temporomandibular Joint Dysfunction Syndrome related services, occlusal adjustments
  • Temporary or provisional dental services and procedures
  • Orthodontic services

    Refer to the policy for a more complete list of exclusions and limitations

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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