Dental PPO and Dental HMO Highlights

This chart is only a summary. For a complete list of benefits, exclusions, and limitations of either dental plan, please refer to the Dental PPO or Dental HMO Supplement to the Service Agreement for your health plan. We will automatically send you a copy of the applicable Supplement when your health plan application is approved. To have a Supplement sent sooner, please call 1-800-431-2809.

	Dental PPO1, 3		Dental HMO2, 4
Service	With Participating Dentists, you pay:	With Non-Participating Dentists, the Plan reimburses you up to:	You pay:
Diagnostic Services Comprehensive Oral Exams	$0	$40	$0
Preventive Care
Prophylaxis (cleanings, every 6 months)
Adult	$0	$48	$0
Child	$0	$34	$0
Sealant/per tooth5 (covered to age 16)	$0	$22	$11
Restorative Services3
One-Surface Amalgam (filling)	$35	$28	$15
Crown (porcelain fused to noble metal)	$320	$256	$300*
Endodontics3
Anterior Root Canal	$156	$125	$155
Molar Root Canal	$234	$187	$290
Periodontics3
Osseous Surgery/per quadrant	$263	$210	$303
Periodontal Root Planing/per quadrant	$65	$52	$75
Removable Prosthetics3
Complete Denture (upper or lower)	$388	$310	$400
Oral Surgery3
Extraction (single tooth)	$37	$30	$30
Removal of Impacted Tooth (complete bony)	$113	$90	$125
Orthodontics3,4
Fully banded (two year) case — child	$2,350**	Not Covered	$2,350**
Fully banded (two year) case — adult	$2,650**	Not Covered	$2,650**

¹ Use any Participating Dentist to take advantage of contracted rates and pay lower out-of-pocket costs. When you use dentists who are not in our network, the Plan reimburses up to the amount listed in the middle column, and you are responsible for all charges in excess of that amount.

² All services must be performed, prescribed, or authorized by your Primary Dental Center, chosen from the Blue Shield Dental HMO Dental Center Directory. If you need to see a specialist, you must get a referral from your Dental Center to receive covered services.

³ Dental PPO members have certain waiting periods. For restorative services: three months for minor procedures, such as fillings; 12 months for major procedures, such as crowns. For endodontics, periodontics, and oral surgery: three months. For orthodontics, and removable and fixed prosthetics: 12 months.

⁴ Dental HMO members have a 12-month waiting period for orthodontics. (There are no waiting periods for other covered services.)

⁵ Coverage for sealants is limited to the first and second permanent molars.

^* Plus the cost of precious or semi-precious metals.

^** Plus up to $250 for records.