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BOR DENTALBlue Cross and Blue Shield
One Time Enrollment
Participating Dentists Network http://www.usg.edu/admin/humex/benefits/dental
National Network (use of non-network providers will be subject to balance billing)
-------------------------- 24 month prior enrollment for replacement of
prosthetics Crown replacement when necessary after 5 years from
installation Surgical extraction of impacted wisdom teeth is not
covered 6 month prior enrollment for access to orthodontic
See detail exclusions pg. 14 of the BOR Indemnity Dental Book
BOR PREVENTIVE DENTAL CARENO DEDUCTIBLE - PLAN PAYS 100%
FLUORIDE TREATMENT
ORAL EXAMINATIONS
PROPHYLAXIS (Cleaning)
X-RAYS
BOR DENTAL CARE AFTER $50 DEDUCTIBLE - PLAN PAYS 80%
ANESTHESIA
EXTRACTIONS
FILLINGS
ROOT CANAL TREATMENT
BRIDGES
CROWNS
DENTURES
INLAYS/ONLAYS
ORTHODONTIC
APPLIANCES & TREATMENT
BOR ORTHODONTIC CARE AFTER $50 DEDUCTIBLE - PLAN PAYS 80%
BOR DENTALBlue Cross and Blue Shield
Lifetime Maximum
($1,000 for orthodontics)
Claim Form
Greater Out-of-Pocket Expense
Calendar Year Maximum ($1,000)
BOR DENTALCOST PER MONTH
-Single $27.24 -Employee/Child $51.74
-Employee/Spouse $54.46 -Family $87.14