2013 Benefit Enrollment Guide - Troy University

Healthcare Benefits
Dental (Blue Cross Blue Shield of AL)
In- Network and Out-of-Network
Dental Coinsurance Covered Procedures
80% Basic Services
• Routine oral examinations (two per calendar year)
• Routine Cleanings (two per calendar year)
• Topical applications of fluoride (children
through age 18, 2x per calendar year)
• Space maintainers (through age 18)
• Dental X-rays (full mouth 1x during any 36
months in a row, Bitewing 2x in a calendar year)
• Sealants*
Dental Benefits are available to you and your eligible family
members to cover routine care, such as exams, x-rays and
cleanings, fillings, and periodontal care.
Orthodontia is not included. Under the BCBS of AL Plan, you
can go to the dental provider within the Dental PPO Network.
If you choose to go to an out-of-network provider, the same
percentages will be paid, but you will be responsible for any
Reasonable or Customary charges.
Dental Summary of Benefits
Dental Expenses
Plan pays after deductible
Basic Services 80%
Supplemental Services 80%
Periodontic Services 80%
Annual Maximum
$1,000 per covered person
Deductible
Individual $25.00
Family
$75.00
(Three $25 deductibles per family maximum)
• Fillings*
• Simple tooth extractions
• Repairs to removable dentures
*Refer to SPD for limitations
80% Supplemental Services
• Oral surgery – tooth extractions and impacted
teeth and to treat mouth abscesses
• General anesthesia
• Treatment of the root tip of the tooth including its removal
80% Periodontic Services
• Periodontic exams 2x each 12 months
• Removal of diseased gum tissue and reconstructing gums
• Removal of diseased bone
• Reconstruction of gums and mucous membranes by surgery
• Removing plague and calculus below the gum line for
periodontal disease
Please call 1-866-688-9727. Troy University 2013 Benefits Enrollment Guide 6