Download dental insurance - Rockford Public Schools

DENTAL INSURANCE
The District offers one dental program, which BlueCross BlueShield of Illinois is the administrator.
The product name is BlueCare Dental PPO, and it is like a medical PPO plan, in that it offers a
large national network of more than 60,500 contracting general and specialty dentists. The plan
gives you the freedom to choose a dentist from within the network or outside the network.
Benefit co-insurance levels are the same for network and non-network dentists.
Network dentists have agreed to accept a pre-determined fee (Maximum Allowance) for their
services, so when you select a BlueCare DPPO dentist, your out-of-pocket cost is less, and you
will not be balanced billed.
You can also see any dental specialist within the BlueCare DPPO
network without a referral.
As stated above, you may see any dental provider you wish; however, if you utilize an out-ofnetwork provider, the plan will pay the provider the lesser of the fee charged or between 50100% of the usual and customary fee charged depending upon the service for that zip code. You
will be obligated to pay any difference between the amount charged and the amount paid by the
plan
To locate a BlueCare DPPO provider visit the web site at www.bcbsil.com. or call Customer
Service at (800) 367-6401
BlueCare® DENTAL
BlueCross~ BlueShield of Illinois
PREFERRED CHOICE (PPO)
ROCKFORD PUBLIC SCHOOL DISTRICT 205
The following is a listing of common services available through your BlueCare Dental PPO Network.
The member's share of the cost is determined by whether care is received from a contracting or non-contracting provider.
.
Benefits
In-Network Provider*
Out-of-Network Provider*
Benefit Period Maximum
$1,500
Deductible
$50 per person per benefit period
$150 maximum per family
Dependent Coverage
Spouse and unmarried dependent up to age 19 or
unmarried, full-time students up to age 23.
Diagnostic & Preventive Services**
Dental exams
Cleanings
X-rays
Fluoride treatment
Miscellaneous Services**
Sealants
Space maintainers
Labs & tests
Emergency Care
Emergency exams - treatment for the relief of pain
100% of Maximum Allowance
100% of Usual & Customary
100% of Maximum Allowance
100% of Usual & Customary
100% of Maximum Allowance
100% of Usual & Customary
80% of Maximum Allowance
80% of Usual & Customary
80% of Maximum Allowance
80% of Usual & Customary
80% of Maximum Allowance
80% of Usual & Customary
80% of Maximum Allowance
80% of Usual & Customary
80% of Maximum Allowance
50% of Maximum Allowance
80% of Usual & Customary
50% of Maximum Allowance
50% of Maximum Allowance
50% of Usual & Customary
50% of Maximum Allowance
50% of Usual & Customary
Restorative Services
Routine fillings (amalgams and resins)
Pin retention
Simple extractions
General Services
Intravenous sedation
Anesthesia
Stainless steel crowns
Endodontic Services
Root canals
Pulp caps
Apicoectomy/Apexification
Oral Surgery Services
Surgical extractions
Alveoloplasty
Vestibuloplasty
Periodontic Services
Scaling & root planing
Gingivectomy/gingivoplasty
Osseous surgery
Crowns, Inlays/Onlays Services
Crowns
Inlays/onlays
Prefabricated posts and cores
Repair and recementation of crowns, inlays/onlays
Prosthodontic Services
Bridges and dentures
Reline/rebase of dentures
Addition of tooth or clasp
Adjustment and repair of bridges and dentures
Orthodontics**
Coverage for dependent children to age 19
50% of Maximum Allowance to the
Orthodontia Lifetime Maximum of $1 ,500
50% of Usual & Customary to the
Orthodontia Lifetime Maximum of $1 ,500
Please note: This information only provides highlights of this program.
* Schedule of Maximum Allowances
Contracting providers have agreed to accept the Schedule of Maximum Allowances as payment in full for covered services. For services received from a noncontracting provider, member will be liable for the difference between the dentist's charge and covered benefits.
** Deductible does not apply.
A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association.