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Dental Reimbursement

View the Dental Reimbursement Guideline below to help determine BCBSWY’s dental reimbursement. The guideline is updated regularly on our website and is provided for reference only. We recommend referring to the website each time you need dental reimbursement information. This guide is subject to change without notice. This information is NOT A GUARANTEE OF PAYMENT. To verify coverage, visit The Healthcare Online Resource (THOR) or
call 1-800-442-2376.

The reimbursement amounts shown are standard and may vary based on the member’s benefit plan. The standard benefit includes a $1,000 per calendar year maximum per member.  Each member is subject to a $50 deductible and $100 family deductible.

Dental reimbursement varies by benefit plan.  To find the appropriate reimbursement, refer to the alpha prefix of the participant’s BCBSWY ID number: ZSA, ZSE, ZSF, ZSH, ZSK, ZSP, or R (Federal Employee Program).

Note: Plans with ID numbers beginning with ZSC, ZSD and ZSM do not have dental benefits.

Dental Reimbursement Guideline

Preventive

Services

Cost Share

Notes

Bitewing X-rays
(2 Sets)

100%

Maximum of 2 per calendar year

Cleanings/ Periodontal Maintenance

100%

Maximum of 2 per calendar year

Fluorides

100%

Maximum of 2 per calendar year (through age 19)

Office Visit

100%

Maximum of 2 per calendar year

Panoramic

100%

(1 series / 36 month per period)

Space Maintainers

100%

(through age 19)

Restorative

Services

Cost Share

Notes

Fillings

ZSP: 80% deductible and coinsurance
ZSA: 50% deductible and coinsurance
ZSE, ZSF, ZSH, ZSK: deductible and coinsurance through age 19 (pediatric dental only)
R: Limited Benefit

No down grading on fillings

Endodontics

Services

Cost Share

Notes

Root Canals (including pulpotomy, pulp capping, and apicoectomy)

ZSP: 80% deductible and coinsurance
ZSA: 50% deductible and coinsurance
ZSE, ZSF, ZSH, ZSK: deductible and coinsurance through age 19 (pediatric dental only)
R: Limited Benefit

 

Oral Surgery

Services

Cost Share

Notes

Impacted Wisdom Teeth

ZSP: 80% deductible and coinsurance
ZSA: 50% deductible and coinsurance
ZSE, ZSF, ZSH, ZSK: deductible and coinsurance through age 19 (pediatric dental only)
R: deductible and coinsurance

 

Simple Extractions

ZSP: 80% deductible and coinsurance
ZSA: 50% deductible and coinsurance
ZSE, ZSF, ZSH, ZSK: deductible and coinsurance through age 19 (pediatric dental only)
R: Limited Benefit

 

Surgical Extractions

ZSP: 80% deductible and coinsurance
ZSA: 50% deductible and coinsurance
ZSE, ZSF, ZSH, ZSK: deductible and coinsurance through age 19 (pediatric dental only)
R: Limited Benefit

 

Periodontics

Services

Cost Share

Notes

Periodontal Scaling and Root Planning

ZSP: 80% deductible and coinsurance
ZSA: 50% deductible and coinsurance
ZSE, ZSF, ZSH, ZSK: deductible and coinsurance through age 19 (pediatric dental only)
R: Not a Benefit

 

Prosthodontics

Services

Cost Share

Notes

Crowns, Bridges, Dentures

ZSA, ZSP: 50% deductible and coinsurance
ZSE, ZSF, ZSH, ZSK: deductible and coinsurance through age 19 (pediatric dental only)
R: Not a Benefit

Crowns, Bridges, and Dentures may be replaced once every 5 years

Crowns and Bridges should only be billed when they are seated

Orthodontics

Orthodontic benefits vary. Please call Member Services at 1-800-442-2376 to inquire.

Typical Non-Covered Services

Sealants, Occusal Guards, TMJ, Implants, Local Anesthesia, Bleaching, and Mouth Guards

 

Questions?
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800-442-2376
Monday-Friday 8 a.m. - 5 p.m.

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