Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and
Blue Shield Association
Dec 19
Page 1 of 5
The following is a listing of common services available through your BlueCare Dental network.
The member’s share of the cost is determined by whether care is received from a contracting or non-contracting provider.
This information only provides highlights of this program. Please refer to the BlueCare Dental Certificate for additional benefit information.
DENTAL BENEFIT HIGHLIGHTS
C o n t r a c t i n g P r o v i d e r * *
Maximum Per Participant
$2,000
General Provisions
Plan Year Deductible
Three-month Deductible carryover applies
Deductible Credit from prior carrier
$50 Individual
$150 Family
No
No
100%
Diagnostic Evaluations (Deductible does not apply)
Periodic Oral Evaluations, for established patients
Problem Focused Oral Evaluation (limited, detailed or extensive) (no limitation)
Comprehensive Oral Evaluations for new or established patients. (2 every 12
months, combined maximum)
Comprehensive Periodontal Evaluations, for new or established patients
Oral Evaluations for children
Preventive Services (Deductible does not apply)
100%
Prophylaxis (2 cleanings every 12 months in combination with Periodontal
Maintenance)
Fluoride Treatment (up to age 19; 2 per every 12 months)
Diagnostic Radiographs (Deductible does not apply)
100%
Dental X-rays (Subject to booklet provision) Full Mouth / Panoramic X-rays (1 time per
36 months.)
Bitewing X-ray Series (1 time every 12 months)
Periapical X-rays (1 time every 12 months)
Miscellaneous Preventive Services (Deductible applies)
80%
Sealants (up to age 16, permanent molars, 1 time per lifetime)
Space Maintainers (up to age 19)
(*) Annual Deductible applies to these categories indicated.
*Basic Restorative Dental Services
80%
Amalgam Restorations (limited to 1 per tooth surface every 24 months)
Resin-based Composite Restorations (limited to 1 per tooth surface every 12
months)
*Non-Surgical extractions
80%
Simple Extractions – Removal of Retained Coronal Remnants & Removal of
Erupted Tooth or Exposed Root
*Non-Surgical Periodontal Services
80%
Periodontal Scaling and Root Planning (1 time per quadrant every 24 months)
Full Mouth Debridement (1 time every 12 months)
Periodontal Maintenance (2 times every 12 months in combination with routine
oral prophylaxis)
*Adjunctive Services
80%
Palliative treatment (emergency)
Deep sedation, General Anesthesia
*Endodontic Services
80%
Therapeutic Pulpotomy/ Pulpal debridement
Root Canal Therapy
Apicoectomy / Apexification
Retrograde filling / Root amputation / Hemisection
WASTE CONNECTIONS US, INC
Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and
Blue Shield Association
Dec 19
Page 2 of 5
*Oral Surgery Services
80%
Surgical Tooth Extractions
Alveoloplasty / Vestibuloplasty
Tumor / Cyst Removal
Bone Tissue Removal
Incision and Drainage of an intraoral abscess
*Surgical Periodontal Services
80%
Gingivectomy / Gingivoplasty (1 time per quadrant every 24 months)
Gingival Flap Procedure (1 time per quadrant every 24 months)
Clinical Crown lengthening
Osseous Surgery / Osseous grafts (1 time per quadrant / site every 24 months)
Soft tissue grafts / allografts (one per site every 24 months)
Distal or proximal wedge procedure
Anatomical crown exposures (one per quadrant every 24 months)
*Major Restorative Services
50%
Single Crown Restorations (1 per tooth every 8 years)
Gold Foil and Inlays/Onlays Restorations (1 per tooth every 8 years)
Labial Veneer Restorations (1 per tooth every 8 years)
Crowns placed over Implants (1 per tooth every 8 years)
*Prosthodontic Services
50%
Complete and Removable Partial Dentures (1 time per 60-month period)
Denture Reline/Rebase (1 time every 36 months /must not be performed within six
months of denture placement)
Fixed Bridgework (once every 8 years)
Prosthetics placed over Implants
Implants)
*Miscellaneous Restorative and Prosthodontic Services
50%
Prefabricated Crowns / Stainless Steel & Resin (Permanent Teeth limited to; 1 time
per tooth every 8 years)
Recementation of Inlays / Onlays / Crowns / Dentures / Bridges / Post & Core
(limited to 2 every 12 months, considered part of initial placement if provided
within 6 months)
Post & Core, Pin Retention, and Crowns & Bridge Repairs
Pulp Cap – direct & indirect
Denture Adjustments (3 times per appliance every 12 months)
Repairs of Inlays / Onlays / Veneers / Crowns / Fixed or Removable Dentures / Clasp
(limited to once per lifetime per tooth or clasp)
Orthodontics
Deductible Waived
Orthodontic Diagnostic Procedures and Treatment:
Adults eligible: ☒ No ☐ Yes If yes age limitation:
Dependent Children eligible: ☐ No ☒ Yes If yes age limitation: 19
Lifetime Maximum per Participant
50%
$1,000
Insured: Coordination of Benefits (COB): ☐ Birthday rule applies (standard)
ASO: Coordination of Benefits (COB):
☒ Birthday rule (standard)
☐ Gender rule
Non-duplication of benefits (COB):
☐ Yes (all benefits combined not to exceed benefits of this program)
Claim filing time limit:
☒ Within 365 days of the date of service (standard)
☐ End of the year following the year of service
☐ Two years from the date of service
☐ Other (explain in additional provisions section below)
Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and
Blue Shield Association
Dec 19
Page 3 of 5
Additional Provisions: Changes from standard to non-standard benefits (with CBSR / AdHoc approval). Account Structure changes, i.e.,
new group & section numbers. Also, indicate renewal benefit changes and the effective date of that change.
Diagnostic and Preventive Class I
1. Oral Evaluations/Exam – two (2) exams, per person per Plan Year.
2. Prophylaxis (cleaning), including Periodontal Maintenance (following active therapy) - limited to two (2) per Plan Year.
3. Fluorides – up to age 12; limited to two (2), per Plan Year.
4. Bitewing X-rays – one (1) per six (6) month period.
5. Screening of a patient – covered as a Diagnostic Benefit.
Miscellaneous Services Class II
6. Sealants up to age 19, posterior teeth, limited to 1 treatment per tooth every 24 months.
7. Space Maintainers with no age limitation, covered.
8. Palliative treatments covered.
Restorative Services Class II
9. Amalgam Fillings – no limitations.
10. Composite/Resin Fillings – no limitations.
11. Adjustments to Complete Denture – covered if more than 6 months after installation; 1 time in 36 months.
General Services Class II
12. Analgesic covered.
Periodontal Services Class II
13. Periodontal Scaling and Root Planing – Entire Mouth – no limitation.
14. Gingivectomy - limited to one in 36 months.
15. Osseous Surgery – 1 in 36-month period.
16. Gingival flap procedure - 1 per 24-month period.
17. Guided Tissue Regeneration - 1 in 36-month period.
Crowns, Inlays/Onlays Class III
18. Crowns, Inlays/Onlays and Veneers - replacements within 5 years after the date of original placement.
Prosthodontic Services Class III
19. Bridges, partials and dentures replacements within 5 years after the date of original placement.
20. Implants – no limitations.
21. Recement of Bridge – no limitations.
Additional Provisions
• Extension of Benefits - 3 calendars months.
o An expense incurred in connection with a Dental Service that is completed after a person's benefits cease will be deemed to be incurred
while insured if:
o for a crown, inlay or onlay, the tooth is prepared while the patient is insured and the crown, inlay or onlay installed within 3
calendar months after their insurance ceases.
o for root canal therapy, the pulp chamber of the tooth is opened while the patient is insured and the treatment is completed within 3
calendar months after their insurance ceases.
o There is no extension for any Dental Service not shown above.
Effective 6/1/2020, D7240 & D7241 are only covered under the dental plan.
Effective 6/1/2022, Plan Year Benefit Maximum changing from $1,500 to $2,000.
☐ BlueMax Advantage – Available only for 151+
Graduated Dental Benefit Maximum: $ Graduated Benefit Start Date:
Number of Increments: _______
Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and
Blue Shield Association
Dec 19
Page 4 of 5
In-Network Increment Amount: $
Out-of-Network Increment Amount: $
Transfer-in (Takeover Credit): ☒ No ☐ Yes: $ and services being Transferred-In:
Missing Tooth Provision (MTP) applies: ☒ No or ☐ Yes (add contractual language below). Effective Date:
An exclusion will apply to expenses involving the replacement of teeth that were missing prior to the effective date of the dental contract.
All other benefits will begin on the first day of coverage. This exclusion will not apply to:
• Any participant who becomes effective on the dental contract date who was covered under a previous group dental
care contract by the Employer.
• Any participant who has been continuously covered for 24 months under a group dental care contract with BCBSTX
which included prosthetic benefits.
• A partial or full denture or fixed bridge which includes replacement of a missing tooth which was extracted after
coverage becomes effective.
☐ Enhanced Dental Benefit -- Available only for 151+
Medical Conditions
☐ Cardiovascular Disease ☐ Diabetes ☐ Pregnancy
Type of Service (check services that will apply)
☐ 100% Benefit Scaling & Root Planing
☐ 100% Benefit Office Exam
☐ 100% Benefit Periodontal Maintenance Cleaning
Additional Benefits (applies only to Pregnancy)
☐ Additional Routine Cleaning
☐ Additional Periodontal Maintenance Cleaning
Benefit Waiting Period – ☒ NO or ☐YES (the information below is required per group request) Effective Date:
NOTE: IF A BENEFIT WAITING PERIOD APPLIES; WAITING PERIOD WAIVED FOR EXISTING GROUP DENTAL PLANS AND/OR TRANSFERS
GROUPS.
Member must be continuously covered under this policy for [xx] months before being eligible for the following Covered Services:
☐ Non-Surgical Periodontal Services
☐ Surgical Periodontal Services
☐ Major Restorative Services
☐ Prosthodontic Services
☐ Miscellaneous Restorative and Prosthodontic Services
☐ Orthodontic Services
**Each time you need dental care; you can choose to:
See a Contracting Provider
See a Non-Contracting Provider
• Your out-of-pocket cost will generally be the least amount
because BlueCare Providers have contracted to accept a
lower Allowable Amount as payment in full for Eligible
Dental Expenses
• You are not required to file claim forms
• You are not balance billed for costs exceeding the
BCBSTX Allowable Amount for BlueCare Dentists
• Your out-of-pocket cost may be greater because Non-
Contracting Providers have not entered into a contract with
BCBSTX to accept any Allowable Amount determination as
payment in full for Eligible Dental Expenses
• You are required to file claim forms
• You are balance billed for costs exceeding the BCBSTX
Allowable Amount
• Out of Network Reimbursement - 90
th
R&C
EMPLOYEE INFORMATION
· This is a general summary of your benefit design. Please refer to your benefit booklet for other details and for limitations and
exclusions.
· The following eligibility provisions apply:
· Dependent children are covered to age 26. Disabled dependent children can be covered beyond age 26.
· Retirees are not eligible for coverage.
· Employees may enroll dependent children up to age 5 on the first of the month following application with no late
enrollment penalty.
· Open enrollment - employees and/or dependents not presently covered may enroll for dental 31 days prior to the
anniversary date.
When the course of treatment will be in excess of $300, a predetermination request should be submitted to BCBSTX in advance of treatment.
Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and
Blue Shield Association
Dec 19
Page 5 of 5
Group Executive Name and Title
(Please type or print)
________________________________
Signature
_ _
Date
Agent of Record Name
(Please print or type)
_______________________________
Signature
_ _
Date
BCBSTX Representative Name
(Please print or type)
_______________________________
Signature
_ _
Date