Download Dental Summary of Benefits - Blue Cross and Blue Shield of Texas

Blue Cross® and Blue Shield® of Texas*
Dental Summary of Benefits Prepared for Oceaneering International, Inc.
TYPE OF SERVICE
GENERAL PROVISIONS
Calendar Year Deductible
Deductible Credit from Prior Carrier
Calendar Year Maximum per Participant
DIAGNOSTIC AND PREVENTIVE CARE BENEFITS (deductible waived)
Oral Examinations (2 exams per cal year)
Prophylaxis (2 cleanings per cal year)
Fluoride Treatment (2 times per cal year – no age limit)
Dental X-rays
Bite-Wing Radiographs ( 1 series of films per cal year)
Complete Series or Panorex Radiographs ( 1 time per 60 months)
Diagnostic Casts (1 time per 24 months)
Extraoral Radiographs ( 2 films per cal year )
Sealants (not covered)
Space Maintainers (once per lifetime to age 19 – includes all adjustments within 6 months of
installation)
MISCELLANEOUS SERVICES
Labs and Tests
Palliative Care
RESTORATIVE SERVICES
Routine Fillings (amalgams and resins – composite resins allow 1 per surface every 3 years)
Pin Retention ( limited to 2 pins per tooth, not covered in addition to Cast Restoration )
GENERAL SERVICES
Intravenous sedation
Injection of antibiotic drugs
Stainless Steel Crowns
ENDODONTIC SERVICES
Root Canals
Direct pulp caps
PERIODONTAL SERVICES
Scaling and root planning (once per quadrant per 12 months)
Osseous surgery (once per quadrant per 36 months)
ORAL SURGERY SERVICES
Simple/Surgical tooth extractions
CROWNS, INLAYS/ONLAYS SERVICES
Occlusal Guards (one per 5 years)
Inlays/Onlays (once per 5 years) and Crowns (once per 7 years) (other than temporary
crowns)
PROSTHODONTIC SERVICES
Bridges (once per 5 years)
Full (once per 5 years) and partial (once per 7 years) dentures
Implants
ORTHODONTIC BENEFITS (after deductible)
Orthodontic Diagnostic Procedures and Treatment (Adult and Child to age 26)
Orthodontic Deductible
Lifetime Maximum per Participant
•
•
BENEFIT
$50/Individual
No
$1,500
100%
80%
80%
80%
80%
80%
80%
80%
50%
Yes
50%
$50
$1,500
This is a general Summary of your benefit design. Please refer to your benefit booklet for other details and for limitations and exclusions.
The following eligibility provisions apply:
•
Dependent children are covered to age 21. Full time students are covered to age 26. Disabled dependent children can be covered
beyond age 21.
•
Retirees are not eligible for coverage.
•
Open enrollment – employees and/or dependents not presently covered may enroll for dental 30 days prior to the anniversary date.
Oceaneering International, Inc. effective 1/1/2009
*A Division of Health Care Service Corporation, a Mutual Legal Reserve Company,
an Independent Licensee of the Blue Cross and Blue Shield Association
REV. 10/20/08
Blue Cross® and Blue Shield® of Texas*
Dental Summary of Benefits Prepared for Oceaneering International, Inc.
•
A preexisting condition exclusion will apply to expenses involving the replacement of teeth that were missing prior to the effective date of
the dental contract. This exclusion will not apply to:
•
Any participant who becomes effective on the dental contract date who was covered under a previous group dental care contract by
the Employer.
•
Any participant who has been continuously covered for 12 months under a group dental care contract with BCBSTX which included
prosthetic benefits.
•
When the course of treatment will be in excess of $200, a predetermination request should be submitted to BCBSTX in
advance of treatment.
Please note that our dental is a “freestanding” product and can be purchased separately from the health product, i.e., an
employee can have only himself covered for health, but have dental for the family and vice versa.
Oceaneering International, Inc. effective 1/1/2009
*A Division of Health Care Service Corporation, a Mutual Legal Reserve Company,
an Independent Licensee of the Blue Cross and Blue Shield Association
REV. 10/20/08