Page 10 - 2013-14 NCACU Benefits & Notices

North Central Area CU 2013-14

Dental Coverage

NCACU BCBSM Traditional Plus Dental Plan #3
Member’s Responsibility (copays and dollar maximums)
Copays
- Class I services None
- Class II services 25% of approved amount
- Class III services 50% of approved amount
- Class IV services 50% of approved amount
Dollar Maximums
- Annual Maximum (for Class I, II and III services) $1,000 per member
- Lifetime Maximum (for Class IV services) $1,000 per member
Class I Services
Oral Exams 100% of approved amount, twice a calendar year
A set (up to 4 films) of bitewing x-rays
- For members age 15 and younger 100% of approved amount, one in a calendar year
- For members age 16 and older 100% of approved amount, one every 24 months
Panoramic or full-mouth x-rays 100% of approved amount, one every 84 months
100% of approved amount, any combination of 6 individual or sets of
Diagnostic x-rays
films each calendar year
Dental prophylaxis (teeth cleaning) 100% of approved amount, twice a calendar year
100% of approved amount, one per tooth every 36 months when applied
Pit and fissure sealants – for members age 16 and younger
to the first and second permanent molars
Palliative (emergency) treatment 100% of approved amount
Fluoride treatment – for members age 14 and younger 100% of approved amount, once a calendar year
Space maintainers – missing posterior (back) primary teeth – 100% of approved amount, once per quadrant per lifetime
for members age 16 and younger
Class II Services
75% of approved amount, replacement fillings covered after 48 months
Fillings – permanent teeth
or more after initial filling
75% of approved amount, replacement fillings covered after 24 months
Fillings – primary (baby) teeth
or more after initial filling
75% of approved amount, three times per tooth per calendar year after
Recementation of crowns, veneers, inlays, onlays & bridges
six months from original restoration
Oral surgery including extractions 75% of approved amount
75% of approved amount, once every 36 months for tooth with one or
Root canal treatment – permanent tooth
more canals
Scaling and root planing 75% of approved amount, once every 46 months per quadrant
75% of approved amount, limited occlusal adjustments covered up to
Limited occlusal adjustments
five times in a 60-month period
75% of approved amount, once every 60 months (repair and reline to
Occlusal biteguards
occlusal biteguards covered once every 60 months)
75% of approved amount, when medically necessary and performed
General anesthesia or IV sedation
with oral surgery
Repairs and adjustments of a partial or complete denture 75% of approved amount, six months or more after it is delivered
Relining or rebasing of a partial or complete denture 75% of approved amount, one every 36 months per arch
Tissue conditioning 75% of approved amount, one every 36 months per arch
Periodontic maintenance 75% of approved amount
Class III Services
Onlays, crowns and veneer restorations – permanent teeth –
50% of approved amount, once every 84 months per tooth
for members age 12 and older
Removal dentures (complete or partial) 50% of approved amount, once every 84 months
Bridges (fixed partial dentures) – for members age 16 and older 50% of approved amount, once every 84 months after original delivery
Endosteal implants – for members age 16 and older who are 50% of approved amount, once per tooth in a member lifetime when
covered at the time of the actual implant placement implant placement is for teeth numbered 2 through 15 & 18 through 31
Class IV Services – Orthodontic services for dependents under age 19
Minor treatment of tooth guidance appliances 50% of approved amount
Minor treatment to control harmful habits 50% of approved amount
Interceptive and comprehensive orthodontic treatment 50% of approved amount
Post-treatment stabilization 50% of approved amount
Cephalometric film (skull) and diagnostic photos 50% of approved amount
Salus Group © Copyright 2013 Page | 10