MEMBERS 19 YEARS OLD AND OLDER. Network dentist Non-network dentist Network dentist Non-network dentist NOTE: If an enrolled member turns 19 years old during the benefit year and continues to be a member under this agreement, this plan will not cover services in excess of the benefit limits listed for “MEMBERS 19 YEARS OLD AND OLDER”. Services previously provided, during the benefit year, are counted in determining whether benefit limits have been met. For a covered dental care service you pay: For a covered dental care service you pay the difference between the charge amount and the allowance plus: For a covered dental care service you pay: For a covered dental care service you pay the difference between the charge amount and the allowance plus: Coverage for replacements limited to one (1) in a 60-month period. Oral Surgery Services Limited to coverage when services are not covered under the member’s medical insurance. • General Anesthesia or IV Sedation Covered as a separate benefit when performed in conjunction with a covered oral surgery procedure(s). 50% 50% 20% 20% • Oral Surgery Services 50% 50% 20% 20% • Biopsies Limited to the biopsy and examination of oral tissue, soft or hard. 50% 50% 20% 20% Occlusal (Night) guards Limited to one (1) every five (5) years. 50% 50% 50% 50% Orthodontic Services (Braces) Predetermination is recommended. Only medically necessary braces are covered. 50% 50% Not Covered Not Covered Blue Cross & Blue Shield of Rhode Island Blue Cross Dental Direct Subscriber Agreement TABLE OF CONTENTS DEPENDENT AGE LIMITS I SUMMARY OF BENEFITS I
MEMBERS 19 YEARS OLD AND OLDER. Network dentist Non-network dentist Network dentist Non-network dentist NOTE: If an enrolled member turns 19 years old during the benefit year and continues to be a member under this agreement, this plan will not cover services in excess of the benefit limits listed for “MEMBERS 19 YEARS OLD AND OLDER”. Services previously provided, during the benefit year, are counted in determining whether benefit limits have been met. For a covered dental care service you pay: For a covered dental care service you pay the difference between the charge amount and the allowance plus: For a covered dental care service you pay: For a covered dental care service you pay the difference between the charge amount and the allowance plus: Diagnostic and Preventive Services • Oral Evaluations One (1) initial or periodic examination or emergency oral evaluation performed by a general dentist including diagnosis and charting per benefit year. N/A N/A 0% 0% Two (2) periodic examination or emergency oral evaluation performed by a general dentist including diagnosis and charting per benefit year. 0% 0% N/A N/A • X-rays Single x-rays limited to 4 per 6 month period. 0% 0% 0% 0% Bitewing limited to one (1) set per benefit year. 0% 0% 0% 0% Limited to one full mouth series (FMX) or panorex per 60-month period. 0% 0% 0% 0% X-rays other than those listed above. 50% 50% 20% 20% • Cleanings (Prophylaxis) Two (2) cleanings per benefit year. 0% 0% 0% 0%
