Page 37 - Empowered Learning for Dyslexic Children Benefits Guide 2022-2023

The Legacy School
Dental Summary

Effective Date:
February 1, 2022
Carefirst Carefirst
BlueDental Plus BlueDental EPO
Plan 5 w/Ortho
(PPO Fee Schedule)
In-Network
Referral Needed No No
Class I:
Preventive/Diagnostic Pd @ 100% Pd @ 100%
Class II: Deductible then
Basic Services Pd @ 80% Based on Fee Schedule
Class III:
Major Services - Deductible then
Surgical Pd @ 80% Based on Fee Schedule
Class IV:
Major Services - Deductible then
Restorative Pd @ 50% Based on Fee Schedule
Class V: (Child & Adult) (child and adult)
Orthodontic Services Pd @ 50% Based on Fee Schedule
- Lifetime Maximum $1,500 $2,000
Deductible ( Class II, III & IV)
Individual $25 $25
Family $75 $75
Out-of-Network
Class I:
Preventive/Diagnostic Pd @ 100% N/A
Class II: Deductible then
Basic Services Pd @ 80% N/A
Class III:
Major Services - Deductible then
Surgical Pd @ 80% N/A
Class IV:
Major Services - Deductible then
Restorative Pd @ 50% N/A
Class V:
Orthodontic Services Pd @ 50%
- Lifetime Maximum $1,500 N/A
Deductible ( Class II, III & IV)
Individual $50 N/A
Family $150 N/A
Annual Maximum
Class I, II, III & IV $2,000 $2,000
Does not apply to Class 1 Does not apply to Class 1
Internet Sites
Doctor Provider Site www.carefirst.com www.carefirst.com
# Rates
Individual $35.38 $20.57
Parent/Child $84.91 $49.37
Employee/Spouse $70.76 $41.14
Family $137.98 $80.22

Until the group is issued, rates can change due to rate modifications/effective date changes, census corrections or
geographic changes. This description of benefits is intended for summary and comparison purposes only and based
Blue Harbor Benefits LLC