Page 15 - Lansing Regional Chamber of Commerce Booklet

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

Class III services

Benefits In-network Out-of-network
Surgical periodontic services:
Gingivectomies and gingivoplasties 50% of approved amount 50% of approved amount
after deductible after deductible
Osseous surgeries for non-pediatric members only 50% of approved amount 50% of approved amount
after deductible after deductible
Gingival flap procedures 50% of approved amount 50% of approved amount
after deductible after deductible
Soft tissue grafts 50% of approved amount 50% of approved amount
after deductible after deductible
Bone replacement grafts for non-pediatric members only 50% of approved amount 50% of approved amount
after deductible after deductible
Prosthodontic services:
Complete dentures – once per 84 months 50% of approved amount 50% of approved amount
after deductible after deductible
Removable partial dentures and fixed partial dentures 50% of approved amount 50% of approved amount
(bridges), including abutment crowns and pontics – once after deductible after deductible
per 84 months for members age 16 and older only
Recementation and repairs of bridges 50% of approved amount 50% of approved amount
after deductible after deductible
Stayplates to replace recently extracted permanent anterior 50% of approved amount 50% of approved amount
(front) teeth after deductible after deductible
Endosteal implants and implant-related services – once per 50% of approved amount 50% of approved amount
tooth per lifetime for teeth numbered 2 through 15 and 18 after deductible after deductible
through 31 for non-pediatric members only

Class IV services – Orthodontic services for dependents under age 19

Benefits In-network Out-of-network
Orthodontics and related services 50% of approved amount 50% of approved amount

BDPPO Plus 100/80/50, Jan 2021
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