PLAN
NETWORK
Value Traditional |
||
|---|---|---|
| Benefits | ||
| Deductible per member1 | $0 | |
| Benefit Maximum per member (in and out of network) | $500 | |
| Diagnostic and Preventive Services | Coinsurance (Contract Pays) | Waiting Period |
| Routine Oral Exams, Cleanings and Consultations | 100% | None |
| All Oral X-Rays | 100% | None |
| Fluoride Treatments, Sealants | Not Covered | N/A |
| Palliative Treatment (Emergency) | 100% | None |
| Basic Services | Coinsurance (Contract Pays) | Waiting Period |
| Space Maintainers | Not Covered | N/A |
| Fillings, Endodontic Therapy, Root Canal | 60% | None |
| Periodontics, General Anesthesia/Sedation, Prosthetic Repairs | Not Covered | N/A |
| Simple Extractions | 60% | None |
| Surgical Extractions, Oral Surgery | 60% | None |
| Crown Repair | Not Covered | N/A |
| Major Services | Coinsurance (Contract Pays) | Waiting Period |
| Bridges, Dentures, Inlays, Onlays, Crowns | Not Covered | N/A |
| Orthodontics | Not Covered | N/A |
| 1Does not apply to diagnostic and preventive services | ||
| See contract and schedule of benefits for coverage exclusions and limitations | ||
| 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. | ||
| *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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