Optional Dental Benefits

Comprehensive Plus includes orthodontic dental services and is available to employers with 25 or more full-time employees.

COMPREHENSIVE I

COMPREHENSIVE II

COMPREHENSIVE PLUS

BASIC
BENEFITS 100%
of Allowable*

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.)

Diagnostic

Oral examinations, including Treatment Plan
Dental X-rays (Mouth X-rays once every 3 years and bitewings 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.