Plan
Plan Name:
Blue Select Premier Dental, Low, NS, OON, BlueShield Dental Network, Dep25, Adult/Family Dental
Issuer Name:
Excellus BlueCross BlueShield
HIOS ID:
78124NY1160005
Annual Benefit Maximum:
$1,250
Plan Brochure Link:
Out of Network Coverage:
Y
Dental Plan Type
Dental Plan Type:
Adult & Family Dental Plan
Plan Information
Dep Age:
Age 25
Plan Type:
PPO
Standard or Non-Standard Plan:
Non-Standard
Waiting Periods:
None
Deductible Adult Individual:
$50
Limit Description:
One dental exam & cleaning every 6 months; X-rays (full mouth and panoramic) every 36 months; Restorations limited to once per tooth surface in 12 consecutive months; Bitewing x-rays - up to 4 per calendar year; Diagnostic photos and facial images 1 per c
Lifetime Benefit Maximum:
N/A
Coverage Level:
Individual
Benefits Excluded from In Network MOOP:
N/A
Benefits Excluded from Out of Network MOOP:
N/A
FDP In Network Cost Sharing Adult Benefits
FDP Office Visit With No Additional Services - Adult:
CI: 0% Coins AD
FDP Oral Evaluation - Adult:
CI: 0% Coins AD
FDP Complete Set of X-Rays - Adult:
CI: 0% Coins AD
FDP Topical Fluoride - Adult:
CI: Not covered
FDP Polishing - Adult:
CI: 0% Coins AD
FDP Sealant (per tooth) - Adult:
CI: Not covered
FDP Spacers - Adult:
CI: Not covered
FDP Simple Extraction - Adult:
CI: 20% Coins AD
FDP Fillings - Adult:
CI: 20% Coins AD
FDP Single Restoration Crowns - Adult:
CI: 50% Coins AD
FDP Pulp Cap - Adult:
CI: 20% Coins AD
FDP Bonding - Adult:
CI: Not covered
FDP Root Canal - Adult:
CI: 20% Coins AD
FDP In Network Cost Sharing Adult Benefits
FDP MOOP Adult Individual:
None
FDP Deductible 2+ Adult Members:
$150
FDP MOOP 2+ Members:
None
FDP Additional In Network Cost Sharing Adult Benefits
FDPA Scaling - Adult:
CI: 20% Coins AD
FDPA Gingivectomy or Gingivoplasty - Adult:
CI: 20% Coins AD
FDPA Gum Surgery - Adult:
CI: 20% Coins AD
FDPA Routine Braces - Adult:
CI: Not covered
FDPA Partial Dentures - Adult:
CI: 50% Coins AD
FDPA Complete Dentures - Adult:
CI: 50% Coins AD
FDPA Dental Implants - Adults:
CI: 50% Coins AD
FDPA Bridges - Adults:
CI: 50% Coins AD
FDPA Veneers - Adult:
CI: 50% Coins AD
FDPA TMJ - Adult:
CI: Not covered
FDP In Network Cost Sharing Pediatric Benefits
FDP Deductible Pediatric Individual:
$50
FDP MOOP Pediatric Individual:
$350
FDP Deductible Pediatric 2+ Children:
$150
FDP MOOP Pediatric 2+ Children:
$700
FDP Dental Check-Up - Child:
CI: 0% Coins AD
FDP Basic Dental Care - Child:
CI: 20% Coins AD
FDP Orthodontia - Child:
CI: 50% Coins AD
FDP Cosmetic Orthodontia - Child:
CI: Not covered
FDP Major Dental Care - Child:
CI: 50% Coins AD
FDP Out of Network Cost Sharing Adult Benefits
FDP Deductible Adult Individual (Out of Network Cost Sharing Adult Benefits):
$50
FDP MOOP Adult Individual (Out of Network Cost Sharing Adult Benefits):
None
FDP Deductible 2+ Members (Out of Network Cost Sharing Adult Benefits):
$150
FDP MOOP 2+ Members (Out of Network Cost Sharing Adult Benefits):
None
FDP Office Visit With No Additional Services - Adult (Out of Network Cost Sharing Adult Benefits):
CI: 0% Coins AD
FDP Oral Evaluation - Adult (Out of Network Cost Sharing Adult Benefits):
CI: 0% Coins AD
FDP Complete Set of X-Rays - Adult (Out of Network Cost Sharing Adult Benefits):
CI: 0% Coins AD
FDP Prophylaxis - Adult (Out of Network Cost Sharing Adult Benefits):
CI: 0% Coins AD
FDP Topical Fluoride - Adult (Out of Network Cost Sharing Adult Benefits):
CI: Not covered
FDP Polishing - Adult (Out of Network Cost Sharing Adult Benefits):
CI: 0% Coins AD
FDP Sealant (per tooth) - Adult (Out of Network Cost Sharing Adult Benefits):
CI: Not covered
FDP Spacers - Adult (Out of Network Cost Sharing Adult Benefits):
CI: Not covered
FDP Simple Extraction - Adult (Out of Network Cost Sharing Adult Benefits):
CI: 20% Coins AD
FDP Fillings - Adult (Out of Network Cost Sharing Adult Benefits):
CI: 20% Coins AD
FDP Single Restoration Crowns - Adult (Out of Network Cost Sharing Adult Benefits):
CI: 50% Coins AD
FDP Pulp Cap - Adult (Out of Network Cost Sharing Adult Benefits):
CI: 20% Coins AD
FDP Bonding - Adult (Out of Network Cost Sharing Adult Benefits):
CI: Not covered
FDP Root Canal - Adult (Out of Network Cost Sharing Adult Benefits):
CI: 20% Coins AD
FDP Scaling - Adult (Out of Network Cost Sharing Adult Benefits):
CI: 20% Coins AD
FDP Additional Out of Network Cost Sharing Adult Benefits
FDP Gingivectomy or Gingivoplasty - Adult:
CI: 20% Coins AD
FDP Gum Surgery - Adult:
CI: 20% Coins AD
FDP Tissue Grafting - Adult:
CI: Not covered
FDP Routine Braces - Adult:
CI: Not covered
FDP Partial Dentures - Adult:
CI: 50% Coins AD
FDP Complete Dentures - Adult:
CI: 50% Coins AD
FDP Dental Implants - Adults:
CI: 50% Coins AD
FDP Bridges - Adults:
CI: 50% Coins AD
FDP Veneers - Adult:
CI: 50% Coins AD
FDP TMJ - Adult:
CI: Not covered
FDP Out of Network Cost Sharing Pediatric Benefits
FDP Deductible Pediatric Individual (Out of Network Cost Sharing Pediatric Benefits):
$50
FDP MOOP Pediatric Individual (Out of Network Cost Sharing Pediatric Benefits):
None
FDP Deductible Pediatric 2+ Children (Out of Network Cost Sharing Pediatric Benefits):
$150
FDP MOOP Pediatric 2+ Children (Out of Network Cost Sharing Pediatric Benefits):
None
FDP Dental Check-Up - Child (Out of Network Cost Sharing Pediatric Benefits):
CI: 0% Coins AD
FDP Basic Dental Care - Child (Out of Network Cost Sharing Pediatric Benefits):
CI: 20% Coins AD
FDP Orthodontia - Child (Out of Network Cost Sharing Pediatric Benefits):
CI: 50% Coins AD
FDP Cosmetic Orthodontia - Child (Out of Network Cost Sharing Pediatric Benefits):
CI: Not covered
FDP Major Dental Care - Child (Out of Network Cost Sharing Pediatric Benefits):
CI: 50% Coins AD
FDP Network Information (Family Dental)
FDP Out of Country Coverage:
N
FDP Out of Service Area Coverage:
Y
FDP Out of Service Area Coverage Description:
Local: lesser of fee schedule or charge
FDP National Network:
N
FDP Network Name:
BlueShield Dental Network
FDP Network URL:
Counties
Broome:
$56.30
Cayuga:
$56.30
Chemung:
$56.30
Chenango:
$57.63
Clinton:
$57.63
Cortland:
$56.30
Delaware:
$57.63
Essex:
$57.63
Franklin:
$57.63
Fulton:
$57.63
Hamilton:
$57.63
Herkimer:
$57.63
Jefferson:
$57.63
Lewis:
$57.63
Livingston:
$55.90
Madison:
$57.63
Monroe:
$55.90
Montgomery:
$57.63
Oneida:
$57.63
Onondaga:
$56.30
Ontario:
$55.90
Oswego:
$57.63
Otsego:
$57.63
Schuyler:
$56.30
Seneca:
$55.90
St Lawrence:
$57.63
Steuben:
$56.30
Tioga:
$56.30
Tompkins:
$56.30
Wayne:
$55.90
Yates:
$55.90