Page 13 - Lansing Regional Chamber of Commerce Booklet

Location/Subgroup: LANSING REGIONAL CHAMBER
Group-Subgroup-Class: 00119070-0001-0001

Class II services

Benefits In-network Out-of-network
Other diagnostic and preventive services:
Diagnostic tests and laboratory examinations 80% of approved amount 80% of approved amount
after deductible after deductible
Space maintainers - for missing posterior primary teeth for 80% of approved amount 80% of approved amount
members to the end of the month of their 15th birthday after deductible after deductible
Panoramic or full-mouth X-rays 80% of approved amount 80% of approved amount
Once per 60 months after deductible after deductible
Emergency palliative treatment 80% of approved amount 80% of approved amount
after deductible after deductible
Minor restorative services:
Amalgam and resin-based composite fillings and fillings of 80% of approved amount 80% of approved amount
similar materials – once per tooth and surface per 48 after deductible after deductible
months for permanent teeth; once per tooth and surface per
24 months for primary teeth
Recementation or repair of posts, crowns, veneers, inlays 80% of approved amount 80% of approved amount
and onlays – three times per tooth per calendar year after deductible after deductible
Extractions and surgical removal of non-impacted teeth 80% of approved amount 80% of approved amount
after deductible after deductible
Non-surgical endodontic services:
Root canal treatments – once per tooth per lifetime 80% of approved amount 80% of approved amount
(retreatment of a root canal 12 or more months after the after deductible after deductible
initial root canal treatment is payable once per tooth per
lifetime)
Therapeutic pulpotomies or pulpal debridement 80% of approved amount 80% of approved amount
after deductible after deductible
Vital pulpotomies on primary teeth 80% of approved amount 80% of approved amount
after deductible after deductible
Apexification 80% of approved amount 80% of approved amount
after deductible after deductible
Non-surgical periodontic services:
Periodontal maintenance – three times per calendar year in 80% of approved amount 80% of approved amount
place of routine dental prophylaxis for pediatric members; after deductible after deductible
two times per calendar year in place of routine dental
prophylaxis for all other members
Periodontal scaling and root planing – once per quadrant 80% of approved amount 80% of approved amount
per 24 months for pediatric members; once per quadrant after deductible after deductible
per 36 months for all other members
Localized delivery of antimicrobial agents – one surface per 80% of approved amount 80% of approved amount
tooth and three teeth per quadrant with a maximum of 12 after deductible after deductible
teeth per year for non-pediatric members only
Limited occlusal adjustments – up to five times per 60 80% of approved amount 80% of approved amount
months for non-pediatric members only after deductible after deductible
Occlusal biteguards (and relines and repairs to occlusal 80% of approved amount 80% of approved amount
biteguards) – once per 60 months for non-pediatric after deductible after deductible
members only

BDPPO Plus 100/80/50, Jan 2021
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