Page 11 - 2023 ANS Benefit Guide - 2-1-23

Dental Option:

BCBS of Oklahoma

PAY PERIOD 24 26 Dependent Information

Employee Only No Cost No Cost Our company offers employees the opportunity to
cover their dependent children. Children can join or
Employee + Spouse No Cost No Cost remain on a parent’s dental plan until age 26.

Employee + Child(ren) No Cost No Cost When a child turns 26, they will lose dental coverage
on the last day of their birth month.
Employee + Family No Cost No Cost

Type of Service (In-Network) Amount Paid

Out of Network is at (90th Percetile)
Preventive Services Covered at 100%; No Calendar Year Deductible (CYD)

Basic Services Covered at 80% After CYD
Major Services Covered at 50% after CYD

Calendar Year Deductible $50 Individual / $150 Family
Annual Maximum $1,500 per person
Waiting Periods for Major Services None

Type of Service Benefit Description

Preventive Services Oral Exams, Cleanings, X-rays, Sealants, Fluoride Treatment

Fillings, Simple Extractions, Space Maintainers, Oral Surgery,
Basic Services
General Anesthesia, Endodontics and Periodontics

Major Services Crowns, Bridges, Dentures, Inlays & Onlays and Implants.

Annual Maximum Applies January 1 to December 31

Up to $1500 Lifetime Max; Available for Adults & Children
Orthodontics
Covered at 50%

NOTE: This is only a brief overview. Please see the Benefit Summary for more details.

Website: www.bcbsok.com or Customer Service : 888-381-9727

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