BOR DENTAL Blue Cross and Blue Shield

1
BOR DENTALBlue Cross and Blue Shield

• One Time Enrollment
• Participating Dentists Network
• http//www.usg.edu/admin/humex/benefits/dental
• National Network
• (use of non-network providers will be subject to
  balance billing)
• --------------------------
• 24 month prior enrollment for replacement of
  prosthetics
• Crown replacement when necessary after 5 years
  from installation
• Surgical extraction of impacted wisdom teeth
  is not covered
• 6 month prior enrollment for access to
  orthodontic
• See detail exclusions pg. 14 of the BOR Indemnity
  Dental Book

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BOR PREVENTIVE DENTAL CARENO DEDUCTIBLE - PLAN
PAYS 100

• FLUORIDE TREATMENT
• ORAL EXAMINATIONS
• PROPHYLAXIS (Cleaning)
• X-RAYS

3
BOR DENTAL CARE AFTER 50 DEDUCTIBLE - PLAN PAYS
80

• ANESTHESIA
• EXTRACTIONS
• FILLINGS
• ROOT CANAL TREATMENT
• BRIDGES
• CROWNS
• DENTURES
• INLAYS/ONLAYS

4
BOR ORTHODONTIC CARE AFTER 50 DEDUCTIBLE - PLAN
PAYS 80

• ORTHODONTIC
• APPLIANCES TREATMENT

5
BOR DENTALBlue Cross and Blue Shield

• Lifetime Maximum
• (1,000 for orthodontics)
• Claim Form
• Greater Out-of-Pocket Expense
• Calendar Year Maximum (1,000)

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BOR DENTALCOST PER MONTH

• -Single 27.24
• -Employee/Child 51.74
• -Employee/Spouse 54.46
• -Family 87.14