Blue Cross BlueShield of Illinois
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BlueCare® Dental PPO

BlueCare® Dental PPO

Benefits1Participating DentistsNon-Participating Dentists2
Deductible applies to Type III Services Only
$50 per member per benefit period;
$150 maximum per family
Calendar Year Maximum Benefit
(per individual)
Type I Services
Space maintainers
100% of Maximum Allowance 50% of Maximum Allowance
Type II Services
Simple Extractions
80% of Maximum Allowance 50% of Maximum Allowance
Type III Services
Oral Surgery
50% of Maximum Allowance after deductible 50% of Maximum Allowance after deductible
Not an insured benefit. Up to a 20% discount, up to a maximum savings of $1,000, is available to you for services received from a participating dentist.
Up to a 20% Discount, up to a maximum savings of $1,000 Not Available

1. Your dental care benefits are highlighted in this chart. To fully understand all the terms, conditions, limitations and exclusions exclusions which apply to your benefits, please read the entire BlueCare Dental PPO Rider.

2. For services received from a non-participating dentist, the member will be responsible for any difference between the dentist’s charges and the maximum allowable charge allowable charge. The maximum allowable charge is based on our network negotiated fees. Further information regarding the maximum allowable charge and network status of dentists is available by calling the toll free telephone number on the back of your dental identification card.

3. Benefit Waiting Period – You must be continuously covered under your rider for twelve (12) months before being eligible for the following covered services: (1) Major Restorative Services; (2) Prosthodontic Services; and (3) Miscellaneous Restorative and Prosthodontic Services.