Dental Benefits

Calendar Year Deductible
(Indiv./Family)*

$50 / $150

$50 / $150

$50 / $150

Calendar Year Benefit Maximum

$1,250

$1,250

$1,250

Diagnostic and Preventive
(includes exams, cleanings
& x-rays)

100%

80%

80

Basic Services
(includes fillings, simple
extractions & oral
surgery)

80%

60%

60%

Major Services
(crowns, inlays/onlays &
dentures)

50%

40%

40%

Orthodontia Services
(only for children in place by age 19)

50% Covered
$1,000 Maximum

50% Covered
$1,000 Maximum

50% Covered
$1,000 Maximum

*Deductible applies to Basic and Major Services only

Blue Dental PPO Providers: The preferred network of coverage in the Blue KC service area. Lowest out-of-pocket costs for covered
services. Outside our service area, providers are available through the GRID Blue Cross and Blue Shield national network.

Blue Dental Choice Providers: The additional network of coverage in the Blue KC service area. Higher out-of-pocket costs for covered
services. Outside our service area, providers are available through the GRID Blue Cross and Blue Shield national network.

Non-Participating Providers: Seeing a non-participating dentist results in the Highest out-of-pocket costs for covered services. Members
may be responsible for filing claims and may be balance billed by the non-participating provider.

Employee

$16.07

Employee + Spouse

$32.51

Employee + Child(ren)

$34.79

Family

$51.55