Dental Coverage California

Authorized Agent

Blue Cross of California*
* is an Independent Licensee of the Blue Cross Association

GERRY CACCAMO
A-ADVANTAGE INSURANCE SERVICES
Calif. Lic #OB22296

1200 E. ROUTE 66 #108 GLENDORA, CALIFORNIA 91740
800-246-3330 or 626-857-9230

INSTANT HEALTH QUOTE

APPLICATION FORMS DOWNLOAD

DENTAL INSURANCE RATES

INDIVIDUAL DENTAL PPO PLAN		VIEW RATES
Individual Dental PPO Plan (7874) from BC Life & Health Insurance Company
Benefit	At a Participating Dentist the plan pays	At a Non-Participating Dentist the plan pays
Annual Maximum Benefit per calendar year	$1,000/member (benefits paid after the deductible and applicable waiting periods are met)
Annual Deductible per calendar year	$50/person (3-member maximum)
Preventive and Diagnostic Care: coverage begins upon approval of your application
Initial oral exam	100%	$25
Periodic oral exam limited to two per member per year	100%	$18
Emergency oral exam	100%	$28
Bitewing x-rays - single film	100%	$16¹
Bitewing x-rays - two films	100%	$18¹
Full mouth x-rays limited to one set every 3 years	100%	$60
Routine cleaning - adult limited to two per adult per year	100%	$39
Routine cleaning - child limited to two per child per year	100%	$30
Cleaning with fluoride limited to two per child per year	100%	$35
Topical fluoride only limited to two per child per year	100%	$14
Basic Dental Care: coverage begins after the policy has been in effect for three continuous months.
Benefit	At a Participating Dentist or Non-Participating Dentist the plan pays
Filling - one surface, primary	$38
Filling - one surface, permanent	$42
Extraction - single tooth (simple)	$49
Extraction - each additional tooth (simple)	$46
Surgical extraction	$84
Removal of impacted tooth soft tissue/partal bony/complete bony	$111/$148/$180
Basic Dental Care: coverage begins after the policy has been in effect for three continuous months.
Benefit	At a Participating Dentist or Non-Participating Dentist the plan pays
Scaling/root planing - per quadrant	$48
Gingivectomy - per tooth/per quadrant	$40/$145
Osseus surgery - per quadrant paid at $62 per tooth to a maximum of $277/quadrant	$277
Root canal - one canal	$154
Root canal - three canals	$242
Crown (except stainless steel)	$264
Stainless steel crown	$57
Pontic	$264
Post and core - in addition to crown	$75
Partial denture (upper or lower)	$308

Amounts listed are what the plan pays. The plan pays either the specified amount, or the actual aomunt charged your dentist, whichever is lower. You pay any charges in excess of the astated benefit.
1.Total benefit for single and bitewing x-rays not to exceed cost of full mouth - $60 at non-participating dentists.