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The traditional Dental benefits are provided
for most dental services.
Under the traditional Plan, Dental plan benefits
cover most dental services for you, your spouse and your eligible dependents.
Benefits are paid at 100%, 90% or 50% of the covered expense, depending on the
service you receive. You do not have to satisfy a deductible. The maximum dental
benefit payable in a calendar year is $1,700 per person.
(The calendar year is January 1 through December 31)
An additional Dental benefit is 50% coverage of most
orthodontic services. There is a lifetime maximum of $2,000 for
orthodontia for each covered person under age 19.
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Covered services |
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Your Dental benefits cover a dentist’s usual charges
which you are required to pay for necessary dental services and supplies, but only to the extent that
such charges are “reasonable and customary.” A reasonable and customary charge is the actual fee
charged by a dentist for a service or supply, but only to the extent that the fee is reasonable.
In determining what constitutes a reasonable and
customary charge, the claims processor takes the following into account:
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The usual fee which the individual dentist most
frequently charges the majority of patients for a service or supply |
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The prevailing range of fees charged in the same
area by dentists of similar training and experience |
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Unusual circumstances or complications requiring
additional time, skill and experience |
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If you have a dental problem that can be treated in
more than one way, the procedure that provides a cost-effective, professionally satisfactory result
is covered. |
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What dental services are covered? |
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Expenses for most dental services are covered at 100%, 90% or 50% of the
reasonable and customary charge. |
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Services covered at 100%
These
services are paid at 100% of the reasonable and customary charge:
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Routine oral exams and cleaning and scaling, but not more
than twice for each covered person during any calendar year |
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Three cleanings per
calendar year if you have a documented history of periodontal disease; a
fourth cleaning is allowed during the two calendar years following periodontic surgery |
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Topical application of
fluoride |
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Space maintainers to
replace prematurely lost teeth for covered children under age 19
(coverage will terminate the end of the day immediately preceding the
covered child’s 19th birthday) |
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Emergency treatment to relieve dental pain |
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Services covered at 90%
These services are paid at 90% of the reasonable
and customary charge:
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Dental X rays, including full mouth X rays once each period
of five consecutive calendar years, supplementary bitewing X rays once in
any calendar year and such dental X rays as required for the diagnosis of a
specific treatment |
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Extractions |
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Oral surgery |
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Fillings made of amalgam,
silicate, acrylic, synthetic porcelain and composites to restore
diseased or accidentally injured teeth |
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Periodontics and treatment of other gum or mouth tissue
diseases |
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Endodontics, including root canal therapy |
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General anesthetics and
intravenous sedation when necessary and used with oral or dental surgery |
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Injection of antibiotics
by the attending dentist |
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Repair or recementing of crowns, inlays, onlays, bridgework
and dentures |
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Relining or rebasing
dentures more than six months after installation, but not more than once
in any period of 36 consecutive months |
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Inlays, onlays, gold fillings or crown restorations but only
when a tooth, as a result of extensive caries or fractures, cannot be
restored with the filling materials described above |
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Services covered at 50%
These services are paid at 50% of the reasonable
and customary charge:
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Initial installation of
fixed bridgework, including inlays and crowns as abutments |
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Initial installation of
partial or full removable dentures, including any attachments and
adjustments during the six months after installation |
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Orthodontia
(teeth straightening), as described in the “What is paid for
orthodontia?” section and |
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Replacement of an
existing partial or full removable denture or fixed bridgework by a new
denture or bridgework, or the addition of teeth to an existing partial
removable denture or to bridgework if: |
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The replacement or addition of teeth is necessary to
replace teeth extracted after the existing denture or bridgework was
installed |
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The existing denture or bridgework cannot be made
serviceable and, if installed under this Plan, at least five years have
passed since its installation |
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The existing denture is an immediate temporary denture
and replacement of a permanent denture occurs within 12 months of the
first installation of the immediate temporary denture |
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Services covered under Hospital Surgical Medical coverage
Benefits are provided under
Hospital-Surgical-Medical coverage for cosmetic bonding of eight front teeth for
children age eight through the end of the calendar year in which they become age
19 if required because of severe staining, but not more frequently than once in
any period of three consecutive years.
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Enhanced
Traditional Dental Program
For more information on the Enhanced
traditional Program go to the "Dentemax" page link.
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| Blue Cross and Blue
Shield of Michigan Filing Instructions |
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Dentists may use the American Dental Association’s claim form or their
own to bill dental Services to Blue Cross and Blue Shield of Michigan.
Blue Cross and Blue Shield of Michigan no longer uses a special Dental
Claim Form. Click
Here for Instructions on filing a
claim with BCBSM. |
