Page 41 - Empowered Learning for Dyslexic Children Benefits Guide 2022-2023

BlueDental EPO

Summary of Benefits

You Pay
DEDUCTIBLE
(does not apply to Preventive & Diagnostic Services) $25 individual / $75 family
ANNUAL MAXIMUM
(does not apply to Preventive & Diagnostic Services and Orthodontic Services) Plan pays up to $2,000
PREVENTIVE & DIAGNOSTIC SERVICES
Examination $0
Prophylaxis $0
Bitewing x-rays $0
Sealants (per tooth) $18
Space maintainers $89-$132
FILLINGS
Amalgam restorations (one surface) $34
SOFT TISSUE MANAGEMENT
Periodontal scaling and root planing $64-$93
Full mouth debridement $63
Periodontal maintenance procedures following active therapy $60
RESTORATIVE SERVICES
Crown - porcelain fused to predominantly base metal $417
Crown - porcelain fused to high noble metal $460
ENDODONTICS - ROOT CANAL THERAPY
Anterior (excluding final restoration) $311
Molar (excluding final restoration) $529
DENTURES AND RELATED PROCEDURES
Complete denture - maxillary or mandibular $535
Partial denture - cast metal framework with resin denture bases $622
Reline complete maxillary or mandibular denture (in dentist's office) $108
Pontic - porcelain fused to high noble metal $514
SURGICAL SERVICES
Osseous Surgery (including flap entry and closure) per quadrant $333-$478
Surgical removal of erupted tooth $108
Removal of impacted tooth - completely bony $198
ORTHODONTIC LIFETIME MAXIMUM
(applies to Orthodontic Services) Plan pays up to $2,000
ORTHODONTIC SERVICES
Comprehensive - adolescent or adult $2,576
Pre-orthodontic treatment visit $40
Orthodontic retention $150
CareFirst payments are based on the CareFirst Allowed Benefit. Only services received from an in-network dentist are covered under the
BlueDental Exclusive Provider Organization (EPO) program.
Summary of Exclusions: Not all services and procedures are covered by your benefits contract. This plan summary is for comparison purposes
only and does not create rights not given through the benefit plan.
MD Benefits issued under policy form numbers: CareFirst of Maryland, Inc.: CFMI/DENTAL/GC (1/19); CFMI/BLUEDENTAL EPO EOC (1/19);
CFMI/BLUEDENTAL EPO DOCS (1/19); CFMI/BLUEDENTAL EPO DOCS LG (4/19); CFMI/BLUEDENTAL EPO SOB I-V (1/19); CFMI/BLUEDENTAL EPO
SOB I-V LG (4/19); CFMI/ELIG/D-V (7/09) and any amendments. Group Hospitalization and Medical Services, Inc.: MD/CF/DENTAL/GC (1/19); MD/
CF/BLUEDENTAL EPO EOC (1/19); MD/CF/BLUEDENTAL EPO DOCS (1/19); MD/CF/BLUEDENTAL EPO DOCS LG (4/19); MD/CF/BLUEDENTAL EPO
SOB I-V (1/19); MD/CF/BLUEDENTAL EPO SOB I-V LG (4/19); MD/CF/ELIG (R. 1/08) and any amendments.

CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc.
CareFirst of Maryland, Inc., Group Hospitalization and Medical Services, Inc., and CareFirst BlueChoice, Inc. are independent licensees of the Blue Cross
and Blue Shield Association. The Blue Cross and Blue Shield Names and Symbols are registered trademarks of the Blue Cross and Blue Shield Association.
SUM4683-1P (6/19) ■ MD Group ■ Plan 1