PLAN
NETWORK
Essential Certified |
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|---|---|---|---|
| Benefits | |||
| Deductible (per adult member each year)1 | $75 | ||
| Deductible (per member under 21 per calendar year)1 | $50 | ||
| Adult benefit maximum per year - members age 21 and older | $1,000 | ||
| Child benefit maximum per year - members under age 21 | Unlimited | ||
| Child out-of-pocket yearly maximum - members under age 21 | $350 for 1 Child $700 for 2 or more children |
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| Child2 No Waiting Period | Adult Contract Pays | Adult Waiting Period | |
| Routine Oral Exams and Cleanings1 | 100% | 100% | None |
| Oral X-Rays1 | 100% | 50% | None |
| Fluoride Treatments1, Sealants1 | 100% | Not Covered | Not Covered |
| Palliative Treatment (Emergency)1 | 100% | 80% | None |
| Basic Restorative (Amalgam, Resin Fillings), Endodontics | 80% | 50% | 6 months |
| Oral Surgery, Surgical Extractions | 80% | 50% | 12 months |
| Simple Extractions | 80% | 50% | None |
| Periodontics - Surgical and Non-Surgical | 80% | 50% | 12 months |
| Crown Repairs | 80% | 50% | 12 months |
| Crowns and Prosthetics (Bridges, Dentures) | 50% | 50% | 12 months |
| Implants - Must meet Dental Necessity Requirements | 50% | Not Covered | Not Covered |
| Orthodontics (Members Under Age 21 Only) | |||
| Medically Necessary | 50% | Not Covered | Not Covered |
| 1Does not apply to diagnostic and preventive services | |||
| To take full advantage of your Blue Dental coverage, choose a dentist who participates in the Advantage Plus network.* Dentists in the Advantage Plus network provide covered services at a significant savings. |
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| *Advantage Plus Network is administered by United Concordia Companies, Inc. United Concordia is an independent company that administers dental benefits on behalf of Blue Cross and Blue Shield of Louisiana. | |||
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