Download Blue Cross and Blue Shield of Texas ASO

Blue Cross and Blue Shield of Texas
ASO - Dental Summary of Benefits Prepared for Weatherford International Ltd.
Account Number: 039865
Group Number: 40285
TYPE OF SERVICE
NETWORK
OUT-OF-NETWORK
$25 per Individual / $50 per
Family
Yes
$2,000
$50 per Individual / $100
per Family
Yes
$1,500
100%
100%
100%
100%
80% after plan ded.
80% after plan ded.
80% after plan ded.
80% after plan ded.
80% after plan ded.
80% after plan ded.
80% after plan ded.
80% after plan ded.
80% after plan ded.
80% after plan ded.
50% after plan ded.
50% after plan ded.
50% after plan ded.
50% after plan ded.
50% after plan ded.
50% after plan ded.
GENERAL PROVISIONS
Calendar Year Deductible
Prior Deductible Credit
Calendar Year Maximum per Participant
(In-network and Out-of-network deductibles and maximums update each other)
DIAGNOSTIC AND PREVENTIVE CARE BENEFITS (Deductible Waived)
Oral Examinations (2 exams per Calendar Year)
Prophylaxis (2 exams per Calendar Year)
Fluoride Treatment (up to age 19; One per calendar year)
Dental X-rays
MISCELLANEOUS SERVICES (Deductible Waived)
Sealants (No age limit – one every 3 years)
Space Maintainers (No age limit)
Labs and Tests
Palliative Care
Perio Maintenance
RESTORATIVE SERVICES
Routine Fillings (amalgams and resins)
GENERAL SERVICES
Intravenous sedation
General Anesthesia
Stainless Steel Crowns
Denture Adjustments
Denture Repairs
Recement Bridge
ENDODONTIC SERVICES
Root Canals
Direct pulp caps
PERIODONTAL SERVICES
Scaling and root planing
Osseous surgery
ORAL SURGERY SERVICES
Simple/Surgical tooth extractions
CROWNS, INLAYS/ONLAYS SERVICES
Inlays, Onlays and Crowns (other than temporary crowns)
IMPLANT SERVICES
PROSTHODONTIC SERVICES
Bridges
Full and partial dentures
ORTHODONTIC BENEFITS
Orthodontic Diagnostic Procedures and Treatment (Child up to age 25 and Adult)
Lifetime deductible applies
Lifetime Maximum per Participant



Yes
50%
$25 Orthodontic ded.
50%
$50 Orthodontic ded.
$2000
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:

Effective 9/1/2011dependents covered to age 26, regardless of marital, student or employment status.

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.
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.

Any participant who has been continuously covered for 24 months under a group dental care contract with BCBSTX which
included prosthetic benefits.
DEN8-FRSTG-PPO-SOB
REV. 05/26/09
* A Division of Health Care Service Corporation, a Mutual Legal Reserve Company,
an Independent Licensee of the Blue Cross and Blue Shield Association
Blue Cross and Blue Shield of Texas
ASO - Dental Summary of Benefits Prepared for Weatherford International Ltd.
Account Number: 039865
Group Number: 40285




When the course of treatment will be in excess of $200, a predetermination request should be submitted to BCBSTX in advance of
treatment.
Accums apply to calendar year deductible, 4th quarter carryover deductible from 2008, annual max and orthodontic lifetime max and
deductible.
Effective 01/01/2011 the plan will add dental implants as covered benefit
Effective 9/1/2012 members who are enrolled in the medical and dental plan and are Pregnant or have Cardiovascular Disease or Diabetes,
will be offered a third scaling and root planning service, routine cleaning and office visit, and periodontal maintenance cleaning per
calendar year. These additional services will be paid at 100% and will apply to the calendar year maximum.
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.
DEN8-FRSTG-PPO-SOB
REV. 05/26/09
* A Division of Health Care Service Corporation, a Mutual Legal Reserve Company,
an Independent Licensee of the Blue Cross and Blue Shield Association