Download - Blue Shield

Blue Shield of California
Dental HMO Plan
Enhanced Dental HMO $0*
THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A
SUMMARY ONLY. THE EVIDENCE OF COVERAGE SHOULD BE CONSULTED FOR A DETAILED
DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS.
ADA Code
D0120
D0150
D0210
D601-603
D1110
D1351
D2330
D3310
D3330
D4341
D7111
D2740
D5110
D5120
D6240
D8080
D8090
ADA Description
Office visit
Diagnostic & Preventive Services
Periodic oral evaluation - established patient
Comprehensive oral evaluation - new or established
patient
Intraoral - complete series of radiographic images
Caries risk management2
Prophylaxis - adult
Sealant - per tooth
Routine Services
Resin based composite - one surface, anterior
Endodontic therapy - anterior tooth (excluding final
restoration)
Endodontic therapy - molar tooth (excluding final
restoration)
Periodontal scaling and root planing - four or more
teeth per quadrant
Extraction of coronal remnants - deciduous tooth
Major Services
Crown - porcelain/ceramic substrate
Complete denture - maxillary
Complete denture - mandibular
Pontic - porcelain fused to high noble metal
Orthodontic Services
Comprehensive orthodontic treatment of the
adolescent dentition
Comprehensive orthodontic treatment of the adult
dentition
None
None
None
Member Pays
$0
$0
$0
$0
$0
$0
$0
$20
$175
$355
$75
$20
$3501
$4001
$4001
$3501
$2,350
$2,650
Please Note:
*
1
2
Pending regulatory approval
Precious and semi-precious metals and porcelain on molar crowns, if used will be charged to the member at the dentist's
cost.
Caries Risk Management - CAMBRA (Caries Management by Risk Assessment) is an evaluation of a child’s risk level for caries
(decay). Children assessed as having a “high risk” for caries (decay) will be allowed up to 4 fluoride varnish treatments
during the calendar year along with their biannual cleanings; “medium risk” children will be allowed up to 3 fluoride varnish
treatments in addition to their biannual cleanings; and “low risk” children will be allowed up to two fluoride varnish
treatments in addition to biannual cleanings. When requesting additional fluoride varnish treatments, the provider must
An independent member of the Blue Shield Association A45659 (1/15)
Calendar year deductible per member
Calendar year maximum per member
Waiting Period
provide a copy of the completed American Dental Association (ADA) CAMBRA form (available on the ADA website).
Benefits are subject to modification for subsequently enacted state or federal legislation.
Some procedures may require costs in addition to the Member copayments. Please refer to the Summary of Benefits for
additional information.