Page 17 - HutsonWood-2023-24-Benefit Guide

Dental Plan

Using in-network It’s important to have regular dental exams and cleanings so problems are detected before they become
dental providers painful — and expensive. Keeping your teeth and gums clean and healthy will help prevent most tooth
decay and is an important part of maintaining your overall health. We offer a dental plan through BlueCross
While you have the option of BlueShield of Tennessee.
choosing any provider, you will
save money when you use
in-network dentists. When using BCBST Dental PPO Per Pay Period Deductions
an out-of-network dental provider, Plan Provisions In-Network Out-of-Network* Coverage Level Plan Name
you will pay more because the
provider has not agreed to charge Annual Deductible $50/$150 $50/$150 Employee Only $11.01
you a negotiated rate. (Individual/Family) Employee + Spouse $21.67
Annual Maximum $2,000 per individual
Employee + Child(ren) $28.14
Orthodontia Lifetime $1,000 $1,000
Maximum Family $43.86
Diagnostic and Preventive *The portion of BCBST’s Non-participating Dentist Fee that will be
paid for Out-of-Network services. The Non-participating Dentist Fee
Services (e.g., X-rays, Covered at 100% Covered at 100% may be less than what the dentist charges and you are responsible for
clean ngs, exams) that difference.
i
**There is a 12-month waiting period for some Major Services.
Basic and Restorative 80% 60% Please consult with your dentist prior to getting treatment.
Services (e.g., fillings)
Major Services**
(e.g., dentures, crowns, bridges) 50% 40%

Orthodontia 50% (only for children up to age 26)

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