Dental Benefits Summary
Important Information
This information provides a summary of the major provisions of the dental insurance plan - it is not a contract. It is intended to highlight the coverage; benefits are determined by the terms of the contract. The Institute intends to continue this benefit plan indefinitely, but reserves the right to modify or terminate the plan at any time with or without notice. Participation in this plan is provided to eligible employees and does not constitute a guarantee of employment, requires continued employment and eligibility and is subject to the terms and conditions of the Plan Document.General Benefit Information
Contacting the Plan Administrator
Blue Cross Blue Shield
Voice (800) 847-1200
(585) 325-3630
TTY (585) 454-2845
Annual Deductible
$25 per individual, $50 family maximum applies to Restorative Services
Annual Maximum
$1,000 per individual applies to Restorative Services
Orthodontia Maximum
$1,000 per lifetime per child under age 19
Unique Exclusions
None
Pricing
Priced according to the Blue Shield Schedule of Allowances. Dentists who participate with Blue Shield agree to accept the Schedule of Allowances. Subscribers who go to a non-participating dentist will be liable for balances over the Schedule of Allowances.
Alternative Benefit Allowance
All covered procedures are subject to an alternative benefit allowance. When there is more than one technique or material type for a dental procedure, the dental plan will reimburse for the procedure that has the lesser allowance. When alternate benefit is enforced, the subscriber's benefits are not intended to interfere with the treatment plan recommended by the dentist. The subscriber and dentist should discuss which treatment is best suited for the patient, and may proceed with the original treatment plan regardless of the benefit determination. If the more expensive treatment is chosen, the subscriber is liable for the balance up to the billed amount.
Predetermination of Benefits
It is recommended that you ask your dentist to request a Predetermination of Benefits on your behalf prior to any extensive service. The information will be sent to you and will show you those services that are covered and those that are not, preparing you to make an informed decision on the treatment plan you choose.
Preventive and Diagnostic Services
| Service | Coverage |
|---|---|
| Cleaning & Exam (twice per calendar year) | Covered at 100% |
| Topical Fluoride application for members under age 19 (twice per calendar year) | Covered at 100% |
| Emergency Palliative Treatment to relieve pain | Covered at 100%, when no other services are rendered |
| Sealants (once per tooth in 36 consecutive months for first and second unrestored permanent molars) | Covered at 100%, for members under age 16 |
| X-rays (full mouth 1 in 3 years, bitewings 1 in 12 months | Covered at 100% |
Restorative Services
All services subject Blue Shield Schedule of Allowances and to the annual deductible and annual maximum.
Fillings
| Service | Coverage |
|---|---|
| Amalgam or composite (anterior) restorations for treatment of cavities (once per tooth per year) | Covered at 50% |
Oral Surgery
| Service | Coverage |
|---|---|
| Routine Extraction | Covered at 50% |
| Non-routine Extraction (Surgical, Soft tissue, Impactions) | Covered at 50% |
Periodontics (Gum and Tissue)
Surgical Procedures
| Service | Coverage |
|---|---|
| Gingivectomy, Osseous Surgery or Mucogingival Surgery (allowed once in 36 months) | Covered at 50% |
Non-Surgical Procedures
| Service | Coverage |
|---|---|
| Periodontal Root Planning/Scaling (allowed once in 24 months) | Covered at 50% |
| Periodontal Maintenance following Surgery | Covered at 50%, allowed twice per calendar year |
Endodontics (Nerve and Pulp)
| Service | Coverage |
|---|---|
| Root Canal Treatment | Covered at 50% |
| Apicoectomy | Covered at 50% |
| Removable Prosthetics | Allowed once every 5 years, combined with Fixed Prosthetics |
| Complete Dentures | Covered at 50% |
| Partial Dentures | Covered at 50% |
| Denture Repair/Adjustment | Covered at 50% |
| Fixed Prosthetics | Allowed once every 5 years, combined with Removable Prosthetics |
| Crowns, Inlays/Onlays, Bridges | Covered at 50% |
Orthodontia Services
| Service | Coverage |
|---|---|
| Orthodontia for children under age 19 | Covered at 50%, subject to the lifetime maximum |
