Page 11 - CHI 2022 Benefits Guide
P. 11
2022
Benefits Guide
Dental Benefits
Good dental health is about more than a pretty smile. Doctors and dentists have linked oral health to your
overall health, emphasizing the importance of brushing your teeth, lossing, and visiting a dentist regularly. To
help you maintain your dental health, C.H.I. ofers dental coverage through Blue Cross Blue Shield of Illinois.
Dental Plan Summary Find a Dentist
Percentages listed below represent the amount of Visit www.bcbsil.com to search for in-network dental
cost paid by the plan. providers. Once on this site, click “Find a Doctor or
Hospital.” On the next page, you’ll be able to either login
BCBSIL if you’ve already registered on BCBS’s site or search the
Calendar Year Deductible BlueCare Dental PPO network as a guest.
Individual $50
Family $150
Calendar Year Maximum In-Network Dentists Can
$1,000 Save You Money
Preventive Care When using an in-network dentist your out-of-pocket
z Oral exams (2 per calendar year) costs are lower. This is because the network of dentists
z Cleanings (2 per calendar year) have agreed to charge lower fees, and your plan’s network
z Bitewing X-rays (2 per calendar year) services cover a larger share of the charges. If you choose
z Complete X-rays (1 every 3 years) to use a dentist who does not participate in the BlueCare
Dental PPO network, your out-of-pocket expenses will
z Fluoride applications (1 per calendar year— 100% be higher, and you are subject to any charges above
for children under age 19) reasonable and customary.
z Sealants (1 per posterior tooth every 3
years—for children under age 16)
z Space maintainers (non-orthodontic—for
children under age 19)
Basic Care
z Fillings
z Simple and surgical extractions
80% after
z General anesthesia deductible
z Oral surgery
z Endodontics/root canals
Major Care*
z Inlays and onlays
z Crowns and implants
z Prosthesis over implant (replacement every 50% after
5 years if current prosthesis cannot be deductible
repaired)
z Bridges and dentures
Orthodontia
Coverage for children under age 19 50%
Lifetime maximum $1,500
This summary is a highlight of the beneit provisions and should not be
relied upon as a complete detailed representation of the plan.
* Inlays, crowns, bridges, and dentures: 1 replacement covered every 5
years if it cannot be repaired.
11
Benefits Guide
Dental Benefits
Good dental health is about more than a pretty smile. Doctors and dentists have linked oral health to your
overall health, emphasizing the importance of brushing your teeth, lossing, and visiting a dentist regularly. To
help you maintain your dental health, C.H.I. ofers dental coverage through Blue Cross Blue Shield of Illinois.
Dental Plan Summary Find a Dentist
Percentages listed below represent the amount of Visit www.bcbsil.com to search for in-network dental
cost paid by the plan. providers. Once on this site, click “Find a Doctor or
Hospital.” On the next page, you’ll be able to either login
BCBSIL if you’ve already registered on BCBS’s site or search the
Calendar Year Deductible BlueCare Dental PPO network as a guest.
Individual $50
Family $150
Calendar Year Maximum In-Network Dentists Can
$1,000 Save You Money
Preventive Care When using an in-network dentist your out-of-pocket
z Oral exams (2 per calendar year) costs are lower. This is because the network of dentists
z Cleanings (2 per calendar year) have agreed to charge lower fees, and your plan’s network
z Bitewing X-rays (2 per calendar year) services cover a larger share of the charges. If you choose
z Complete X-rays (1 every 3 years) to use a dentist who does not participate in the BlueCare
Dental PPO network, your out-of-pocket expenses will
z Fluoride applications (1 per calendar year— 100% be higher, and you are subject to any charges above
for children under age 19) reasonable and customary.
z Sealants (1 per posterior tooth every 3
years—for children under age 16)
z Space maintainers (non-orthodontic—for
children under age 19)
Basic Care
z Fillings
z Simple and surgical extractions
80% after
z General anesthesia deductible
z Oral surgery
z Endodontics/root canals
Major Care*
z Inlays and onlays
z Crowns and implants
z Prosthesis over implant (replacement every 50% after
5 years if current prosthesis cannot be deductible
repaired)
z Bridges and dentures
Orthodontia
Coverage for children under age 19 50%
Lifetime maximum $1,500
This summary is a highlight of the beneit provisions and should not be
relied upon as a complete detailed representation of the plan.
* Inlays, crowns, bridges, and dentures: 1 replacement covered every 5
years if it cannot be repaired.
11
