Blue Cross Dental PPO

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PPO Brochure with Application	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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