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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.