Pediatric
Dental
Plans
Pediatric dental is an essential health benefit, available for purchase with every Blue Shield medical plan. To expand your pediatric dental benefit options, Blue Shield provides four pediatric dental plans to choose from (two PPOs and two HMOs) – each of which can be bundled with your medical plan.
Pediatric dental plan highlights:
-
No charge for diagnostic and preventive services
-
All plans cover orthodontics
-
Benefits for minor restorative services, such as fillings, with no waiting periods
-
Provides benefits for major restorative services, such as extractions and crowns, with no waiting periods
Pediatric Dental Plans – Benefit Overview
| Benefits | Preferred Dental HMO Pediatric $0 | Enhanced Dental HMO Pediatric $20 | Preferred Dental PPO Pediatric 50/01 | Enhanced Dental PPO Pediatric 60/01 |
|---|---|---|---|---|
| With participating providers, you pay: | With participating providers, you pay: | With participating providers, after the deductible, you pay: | With participating providers, after the deductible, you pay: | |
| Office visit: | $0 | $20 | N/A | N/A |
| Diagnostic
and preventive
services (includes but is not limited to cleanings, X-rays, initial and periodic oral examinations, topical fluoride treatment) |
$0 | $0 | 0%5 | $0 |
| Restorative
services -
fillings (amalgam or composite resin) |
$402 | $952 | 20% | 50% |
|
Oral surgery (removal of impacted teeth) Endodontics (root canal) Periodontics
(root planing/scaling) |
$3653 | $3653 | 50% | 50% |
| Crowns
and fixed
bridges (includes but is not limited to crowns [resin-based composite, porcelain, porcelain with metal, full metal, gold only, three-quarter crown, stainless steel] and fixed bridges [which are cast porcelain baked with metal, or plastic processed to gold]) |
$3653 | $3653 | 50% | 50% |
| Removable
prosthetics (includes but is not limited to dentures [full maxillary, full mandibular, partial upper, partial lower, teeth, clasps, and stress breakers]) |
$3653 | 3653 | 50% | 50% |
| Orthodontics (Medically necessary) |
$1000 | $1000 | 50%5 | $50%5 |
| Local and general anesthetics | $0 | $0 | 0% | 0% |
| Calendar year deductible | $0 | $0 | $50 per child/$100 per family | $60 per child/$120 per family |
| Calendar year out-of-pocket maximum (includes deductible) | $1000 per child (2 child max)4 | $1000 per child (2 child max)4 | $1000 per child (2 child max)4 | $1000 per child (2 child max)4 |
| Calendar year benefit maximum per member | N/A | N/A | No limit when using participating providers | No limit when using participating providers |
This is an overview only. More detailed benefit information, including benefit information for non-participating providers, will be available by October 1, 2013.