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Dental Benefits

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For BlueJourney HMO and BlueJourney PPO Members

You’ll receive two routine dental visits per calendar year including:

  • Cleaning
  • Bitewing X-rays (Set of 2)
  • Oral Exam

Our BlueJourney HMO and PPO benefits offer 50 percent of the allowed amount for the following services:

Non-routine dental services:

  • Palliative Emergency Treatment
  • Periapical X-rays

Major Restorative Services:

  • Amalgam and composite fillings
  • Crowns
  • Inlays and onlays

Endodontics and Extraction Services:

  • Simple extractions (non-surgical)
  • Prosthodontics (including dentures) and adjustments
  • Repairs of prosthodontics

The plan has a maximum benefit coverage of $2000 for non-routine dental services.

Important Information:

  • Authorizations and referrals are not required for routine dental services. Referrals are not required for comprehensive non-Medicare-covered dental services.
  • Coverage for simple extractions (non-surgical extractions) are typically performed by a general dentist. Surgical extractions are typically performed by an oral surgeon are not covered. (Members should confirm whether or not surgical extractions are covered under the Medicare medical plan.)
  • Excludes coverage for cosmetic procedures (such as veneers, bleaching, and teeth straightening), dental implants, periodontics, other oral/maxillofacial surgery and any other services not listed as covered.
  • Pre-treatment estimates: If a member isn’t sure of the benefits for a specific course of treatment, or treatment costs are expected to exceed $300, we recommend a pre-treatment estimate. Members should ask the treating provider to submit the claim form in advance of performing the proposed services.
  • Pre-treatment estimate requests are not required but may be submitted for more complicated and expensive procedures, such as simple extractions, crowns and bridges. The member will receive an estimate of the costs and how much our plan may pay before treatment begins.
  • PPO benefits reflect in-network coverage

For information about your dental benefit, check your Evidence of Coverage or contact us at 800.779.6962 (TTY: 711), Monday through Friday, 8:00 am - 8:00 pm.

Nominate your dentist

Need to file a claim?

Participating providers and some non-participating providers will submit claims for you. You can mail a dental claim form to:

BlueCross Dental

P.O. Box 1126 
Elk Grove Village, IL 60009

Dental benefits are issued by Capital Advantage Assurance Company®, a subsidiary of Capital BlueCross.

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Updated October 1, 2018

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