Page 14 - 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
Adjustments, repairs, relines, rebases and tissue
conditioning for removable prosthetic appliances:
Relines or rebases of partial dentures or complete dentures 80% of approved amount 80% of approved amount
– once per 36 months per arch after deductible after deductible
Tissue conditioning – once per 36 months per arch 80% of approved amount 80% of approved amount
after deductible after deductible
Adjunctive general services:
General anesthesia or IV sedation 80% of approved amount 80% of approved amount
after deductible after deductible
Office visits for observation (during regularly scheduled 80% of approved amount 80% of approved amount
hours) for non-pediatric members only after deductible after deductible
Office visits after regularly scheduled hours 80% of approved amount 80% of approved amount
after deductible after deductible
House and hospital calls for non-pediatric members only 80% of approved amount 80% of approved amount
after deductible after deductible
Antibiotic injections for non-pediatric members only 80% of approved amount 80% of approved amount
after deductible after deductible

Class III services

Benefits In-network Out-of-network

Major restorative services:
Onlays, crowns and veneers – once per permanent tooth 50% of approved amount 50% of approved amount
per 60 months for members age 12 and older only after deductible after deductible
Substructures, including cores and posts 50% of approved amount 50% of approved amount
after deductible after deductible
Oral surgery services other than extractions of non-
impacted teeth:
Surgical exposure and facilitation of eruption of unerupted 50% of approved amount 50% of approved amount
teeth after deductible after deductible
Incision and drainage of celluliitis or fascial space 50% of approved amount 50% of approved amount
abscesses of intraoral soft tissue after deductible after deductible
Removal of exostoses (excess bony growths of the upper 50% of approved amount 50% of approved amount
and lower jaw) after deductible after deductible
Excision of hyperplastic tissue per arch 50% of approved amount 50% of approved amount
after deductible after deductible
Soft tissue biopsies for pediatric members only 50% of approved amount 50% of approved amount
after deductible after deductible
Frenulectomies 50% of approved amount 50% of approved amount
after deductible after deductible
Surgical endodontic services:
Apical surgeries on permanent teeth 50% of approved amount 50% of approved amount
after deductible after deductible

BDPPO Plus 100/80/50, Jan 2021
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