Optional Dental Benefits - Outline of Benefits

Optional Dental Benefits

Comprehensive Plus includes orthodontic dental services and is available to employers with 25 or more full-time employees. Dental coverage only is not available and cannot be reinstated if medical coverage is cancelled.

COMPREHENSIVE I
COMPREHENSIVE II
COMPREHENSIVE PLUS

BASIC
BENEFITS 100%
of Allowable*

    Diagnostic
  • Oral examinations, including Treatment Plan
  • Dental X-rays (Mouth X-rays once every 3 years and bitewings once every 6 months
    Preventive
  • Fluoride treatment (members under age 19 and no more than once every 6 months)
  • Oral prophylaxis (cleaning), consisting of scaling and polishing (Limited to once every 6 months.)

ADDITIONAL BASIC BENEFIT 80% of Allowable*

    Preventive
  • Space maintainers
    Diagnostic
  • Pulp vitality tests
    Restorative
  • Fillings consisting of dental amalgam and tooth colored synthetic materials
    Oral Surgery
  • Fracture or dislocation treatment
  • Diagnosis and treatment of abscesses and removal of cysts
  • Surgical extractions including impaction
  • Simple extractions
  • Biopsies of oral tissue
    Endodontics (roots and pulp)
  • Root canal treatment
  • Pulp capping
  • Pulpotomy (removal of dental pulp and pulpal therapy)
  • Hemisection
  • Apidectomy

PERIODONTIC BENEFITS 60% of Allowable*
(gum and bone)

  • Surgical periodontic examination
  • Gingival curettage
  • Gingivectomy and gingivoplasty
  • Osseous surgery, including flap entry and closure
  • Mucogingivoplastic surgery
  • Management of acute infection and oral lesions

PROSTHETIC BENEFITS 60% of Allowable* (teeth replacement)

  • Removable dentures, full and partial bridges, fixed and removable
  • Dentures rebase or reline
  • Fixed bridge repairs
  • Repair of removable dentures
  • Crowns, inlays and onlays

Note: Benefits for the replacement of dentures shall not be provided within less than five (5) years of placement or replacement

ORTHODONTIC BENEFITS 50% of Allowable*

  • Diagnosis (including examination, study models, radiographs and all other aids used to determine orthodontic needs)
  • Placement of appliance
  • Active and retention treatments

Note: Orthodontic Services are provided for correction of malocclusion if prescribed by a Treatment Plan approved by Blue Cross & Blue Shield of Mississippi.

Additional dollar limitations will apply to diagnosis, placement of appliance and the monthly active and retention treatments.

Groups of 2 or more
Groups of 25 or more
Not Subject to Deductible
$50 Deductible per Member per Calendar Year
$100 Lifetime Deductible
$1,000 Maximum per Member per Calendar Year
$1,000 Lifetime Maximum per Member

*Allowable means the lesser of (1) Covered charges or (2) the amount established by the Company as amount for dental services covered under the Benefit Plan.