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The chart below provides highlights of your dental coverage
for the
Trooper Chapter, Airport Police
and Fire Officers Chapter, Fairbanks Police Department, and
Juneau Police Department members, as of July 1, 2005. Refer to your
Benefit
Booklet for details, general limitations and exclusions.
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Diagnostic
and Preventive
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Basic
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Major
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Individual
|
Family
|
Individual
|
Family
|
Individual
|
Family
|
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Annual deductible*
|
None |
None |
$25 |
$75 |
$25 |
$75 |
|
Amount plan pays
|
100% of eligible charge |
85% of eligible charge after you meet the
deductible |
50% of eligible charge after you meet the
deductible |
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Dental benefits maximum
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$1,500 per calendar year per person
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Covered services
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- Up to two routine oral examinations
- Prophylaxis
- Topical application of fluoride – under age 20)
- Dental x rays (either complete series or
panoramic once every 36 consecutive months)
- Space maintainers – under age 20
- Sealants for permanent teeth – under age 14
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- Simple extractions
- Oral surgery
- Fillings (one per 24 consecutive months, per tooth
surface)
- Up to two periodontal treatments in any 12 consecutive
months
- Endodontic treatment
- Repair of crowns, inlays, bridgework, and dentures
- Emergency palliative treatment
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- Covered restorations (Inlays, onlays, veneers, and
crowns)
- Initial installation of partial/complete dentures
- Initial installation of fixed bridgework
- Replacement of partial/complete dentures and
fixed bridgework
- Relining/ rebasing dentures
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Pre-estimate of benefits
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Your dentist should submit a pre-estimate
of benefits request for any proposed dental service or
series of dental services for which the total charge will
exceed $450. |
* A deductible is the amount you must pay for
Basic and Major covered services each calendar year before
benefits are payable.
Blue Cross Blue Shield of
Alaska
Customer Assessment Manager
P.O. Box 327
Seattle, WA 98111-0327
Seattle Area: 425-670-5900
Outside Seattle Area: 1-800-345-6784
Hearing-impaired TTY: 425-670-4022 (within Seattle area)
Hearing-impaired TTY:1-800-842-5357 (outside the Seattle area)
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