Senior Dental Coverage - Blue Cross Blue Shield of Georgia

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Major Dental Care• Coverage begins after the Plan has beenin effect for twelve continuous months.• The benefit schedule is the same for alldentists, but you may pay more if youchoose a non-contracting dentist.PROCEDUREPLAN PAYSScaling/Root Planing per Quadrant $41Gingivectomy or Gingioplasty - per tooth $26Gingivectomy - per quadrant $120Root Canal - 1 canal(excl. Final restoration) $130Root Canal - 2 canals(excl. Final restoration) $155Root Canal - 3 canals(excl. Final restoration) $195Crown (except stainless steel) $215Pontic $215Complete Denture (upper or lower) $255Partial Denture (upper or lower) $235Denture Reline (chair-side) $55Denture Reline (lab) $707
Eligibility and EnrollmentTo be eligible for enrollment, you must be:• 65 years of age or older.• A resident of the State of Georgia whoapplies for coverage and is acceptedby BCBSGa.• A resident of the United States for atleast six months.• Not enrolled under any other individualor group dental policy.Date Coverage BeginsThe effective date of your coverage is printedon your member ID card. Your coverage willstay in effect, with our consent, on a monthlybasis.Terms of CoverageCoverage under this Plan remains in force aslong as the required premiums are paid ontime and as long as the policyholder remainseligible for coverage. BCBSGa has the rightto cancel or modify this Plan or change thepremiums of this Plan after 60 days writtennotice to the policyholder. However,BCBSGa will not cancel or modify this Planon an individual basis, but only for allpolicyholders covered under the same Plan.8
Page 1 and 2: SeniorDental CoverageTake Complete
Page 3 and 4: Dental coverage on day oneYou expec
Page 5 and 6: Let us help you understandyour bene
Page 7: Basic Dental Care• Coverage begin
Page 11 and 12: Conditional ReceiptTHIS RECEIPT DOE
Page 13 and 14: ACCESS TO YOUR DATAYou have the rig
Page 15 and 16: Sign me up.To enroll, simply comple

Senior Dental Coverage - Blue Cross Blue Shield of Georgia

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