Dental Blue Select PLAN COMPARISON FEATURES Standard Complete Enhanced (Orthodontia optional) (Orthodontia optional) Routine exams/ cleaning (1 Routine exams/ cleaning (2 Routine exams/ cleaning (2 per benefit period) per benefit period) per benefit period) Bitewing X-rays Bitewing X-rays Bitewing X-rays (1 per benefit period) (1 per benefit period) (1 per benefit period) Fluoride Treatment Fluoride Treatment Fluoride Treatment Diagnostic & Preventive (1 per benefit period, (1 per benefit period, (1 per benefit period, Coverage (100%) children under age 19) children under age 19) children under age 19) Emergency treatment for Emergency treatment for Emergency treatment for pain pain pain Sealants for children ages Sealants for children ages Sealants for children ages 6 through 15 6 through 15 6 through 15 Simple restorative services Simple restorative services Simple restorative services Basic Coverage (80%) Simple removal Simple teeth removal Simple removal Standard or Complete Periapical X-rays Plan: 6 month waiting period Full mouth X-rays (1 per 36 months) Enhanced (with or Endodontics without Orthodontia): No waiting period Periodontics Endodontics Periapical X-rays Surgical teeth removal & oral surgery Periodontics Full X-rays (1 per 36 months) Anesthesia Surgical teeth removal & oral surgery Endodontics Space maintainers Anesthesia Periodontics Major restorative services Surgical teeth removal & Space maintainers oral surgery Dental implants Major Coverage (50%) X-rays of the roots Anesthesia Prosthodontics 12 month waiting period all plans Full mouth X-rays Space maintainers Denture relines (1 per 36 months) Major restorative services Recementations and repair of crowns, inlays, bridges Prosthodontics and dentures Denture relines Recementations and repair of crowns, inlays, bridges and dentures No deductible No deductible Optional Orthodontia 50% Coverage 50% Coverage Coverage Not available -Lifetime Maximum* Lifetime Maximum* 12 month waiting period Available options: $1,000 or Available options: $1,000 or $1,500 $1,500 Children under age 19 Children under age 19
Dental Blue Select PLAN COMPARISON FEATURES Standard Complete (Orthodontia optional) Enhanced (Orthodontia optional) Diagnostic & Preventive Coverage (100%) Routine exams/ cleaning (1 per benefit period) Bitewing X-rays (1 per benefit period) Fluoride Treatment (1 per benefit period, children under age 19) Emergency treatment for pain Sealants for children ages 6 through 15 Routine exams/ cleaning (2 per benefit period) Bitewing X-rays (1 per benefit period) Fluoride Treatment (1 per benefit period, children under age 19) Emergency treatment for pain Sealants for children ages 6 through 15 Routine exams/ cleaning (2 per benefit period) Bitewing X-rays (1 per benefit period) Fluoride Treatment (1 per benefit period, children under age 19) Emergency treatment for pain Sealants for children ages 6 through 15 Basic Coverage (80%) Standard or Complete Plan: 6 month waiting period Enhanced (with or without Orthodontia): No waiting period Simple restorative services Simple removal Simple restorative services Simple teeth removal Simple restorative services Simple removal Periapical X-rays Full mouth X-rays (1 per 36 months) Endodontics Periodontics Major Coverage (50%) 12 month waiting period all plans Endodontics Periodontics Surgical teeth removal & oral surgery Anesthesia Space maintainers X-rays of the roots Full mouth X-rays (1 per 36 months) Periapical X-rays Full X-rays (1 per 36 months) Endodontics Periodontics Surgical teeth removal & oral surgery Anesthesia Space maintainers Major restorative services Prosthodontics Denture relines Recementations and repair of crowns, inlays, bridges and dentures Surgical teeth removal & oral surgery Anesthesia Space maintainers Major restorative services Dental implants Prosthodontics Denture relines Recementations and repair of crowns, inlays, bridges and dentures Optional Orthodontia Coverage 12 month waiting period Not available No deductible 50% Coverage -Lifetime Maximum* Available options: $1,000 or $1,500 Children under age 19 No deductible 50% Coverage Lifetime Maximum* Available options: $1,000 or $1,500 Children under age 19
2018_Dental_Blue_Select_Proposal.docx