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BOR DENTAL Blue Cross and Blue Shield

BOR DENTAL Blue Cross and Blue Shield. One Time Enrollment Participating Dentists Network http://www.usg.edu/admin/humex/benefits/dental National Network (use of non-network providers will be subject to balance billing) --------------------------

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BOR DENTAL Blue Cross and Blue Shield

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  1. BOR DENTALBlue Cross and Blue Shield • One Time Enrollment • Participating Dentists Network • http://www.usg.edu/admin/humex/benefits/dental • National Network • (use of non-network providers will be subject to balance billing) • -------------------------- • 24 month prior enrollment for replacement of prosthetics • Crown replacement when necessary after 5 years from installation • Surgical extraction of impacted wisdom teeth is not covered • 6 month prior enrollment for access to orthodontic See detail exclusions pg. 14 of the BOR Indemnity Dental Book

  2. BOR PREVENTIVE DENTAL CARENO DEDUCTIBLE - PLAN PAYS 100% • FLUORIDE TREATMENT • ORAL EXAMINATIONS • PROPHYLAXIS (Cleaning) • X-RAYS

  3. BOR DENTAL CARE AFTER $50 DEDUCTIBLE - PLAN PAYS 80% • ANESTHESIA • EXTRACTIONS • FILLINGS • ROOT CANAL TREATMENT • BRIDGES • CROWNS • DENTURES • INLAYS/ONLAYS

  4. BOR ORTHODONTIC CARE AFTER $50 DEDUCTIBLE - PLAN PAYS 80% • ORTHODONTIC • APPLIANCES & TREATMENT

  5. BOR DENTALBlue Cross and Blue Shield • Lifetime Maximum • ($1,000 for orthodontics) • Claim Form • Greater Out-of-Pocket Expense • Calendar Year Maximum ($1,000)

  6. BOR DENTALCOST PER MONTH • -Single $27.24 • -Employee/Child $51.74 -Employee/Spouse $54.46 • -Family $87.14

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