HARTWICK COLLEGE
PRIME BLUE DENTAL COVERAGE
The Prime Blue Dental Plan is designed to encourage preventive dental care by providing full coverage for
diagnostic and preventive services. Basic dental services are also covered in full so that minor dental problems can
be taken care of before they become expensive major problems. Major dental services are available at 50% or 80%
payment levels with $50 per person per year ($150 family maximum) deductible.
The level of reimbursement is the Maximum Amount Payable (MAP). Calendar year maximums (excluding
Orthodontic Services) also apply, with the amount dependent on the benefit combination selected.
& CLASS I - Preventive Services - Covered in full by participating dentists
Initial and periodic oral examinations
X-rays
Test and laboratory examinations
Prophylaxis (cleaning)
Fluoride application
Emergency
& CLASS II - Basic Dental Services - Covered in full by participating dentists
Space maintainers
Restorations (fillings)
Extractions
Endodontics
Oral Surgery
& CLASS III - Major Dental Services
Payment level = 50% or 80% of MAP
Deductible = $50 per person per year ($150 maximum)
Inlays, onlays, gold foil restorations, and single crowns
Prosthetic services, dentures and bridges
Periodontics
& ADDITIONAL RIDERS AVAILABLE
Student to age 25
Dependent to age 25
& CLASS IV - Orthodontics
Payment level = 50% or 80% of MAP
At Commencement of active treatment, Blue Cross and Blue Shield of Central New York will reimburse the
subscriber 75% of the total approved allowance based on the treatment plan provided by the dentist.
The remaining 25% of the approved allowance is reimbursed approximately 6 months prior to patient entering
retention.
& ADDITIONAL RIDERS AVAILABLE
Student to age 25
Dependent to age 25
PREVENTIVE SERVICES - CLASS I
These services are paid at 100% of the MAP
Initial and periodontic oral examinations - Two routine dental examinations are covered in any 12-month period.
X-rays - This includes full-mouth x-rays (not more than one set in any 36 consecutive months), supplementary
bitewing x-rays (not more than two sets in any 12 month period), and all other dental x-rays needed for the diagnosis
of a specific condition requiring treatment.
Test and laboratory examinations - Benefits are provided for bacteriologic culture, pulp vitality, and other
miscellaneous laboratory tests in connection with examinations.
Prophylaxis (cleaning) - Coverage provided is limited to two cleanings in any 12-month period.
Fluoride application - Benefits are provided for four topical applications of sodium fluoride in 12 consecutive
months for covered dependents to age 19.
Emergency - Benefits are provided for emergency dental procedures to temporarily alleviate pain or discomfort but
which do not effect a lasting cure.
BASIC DENTAL SERVICES - CLASS II
The following services are paid at 100% of the MAP:
Space maintainers - Benefits are provided to replace prematurely lost or extracted teeth for eligible children under
age 19.
Restorations (fillings) - Benefits are provided to cover single and multiple surfaces, and pin-retained restorations of
the teeth utilizing amalgam, silicate, acrylic or plastic materials.
Extractions - This includes simple or surgical extractions.
Endodontics - Coverage for the treatment of diseases of the dental pulp including root canal therapy.
Oral surgery - Benefits are provided for alveoloplasty (surgical preparation of the ridge for denture), tooth
replantation, biopsy of oral tissue, and stomaplasty (removal and restoration of gum tissue). Also included is
medically necessary general anesthesia administered by a dentist in connection with a covered oral surgery
procedure or extraction.
MAJOR DENTAL SERVICES - CLASS III
The Major Dental Services class of Prime Blue Dental allows you to choose either an 80% or 50% of the MAP
payment level. A $50 per person, per year, deductible also applies to the major dental services listed below.
Inlays, onlays, gold restorations and crowns - Benefits are provided for procedures to restore diseased or
accidentally broken teeth by crowns, inlays (gold filling put into the tooth), onlays (covers the top of the tooth, gold
foil or cast). These procedures are covered only when the tooth cannot be restored by conventional means.
Prosthetic services, dentures and bridges - Benefits are provided for the construction, placement, insertion, and
repair of natural teeth by artificial devices, including bridges and dentures. Benefits also are provided for
installation or fixed bridge work (including inlays and crowns as abutments) and placements of full or partial
dentures. The replacement of a lost, missing or stolen prosthetic device isn=t covered.
Periodontics - Benefits are provided for treatment of diseases of the gums and tissues of the mouth including
gingivitis.
ORTHODONTICS - CLASS IV
The Orthodontics class of Prime Blue Dental allows you to choose either an 80% or 50% of MAP payment level.
Coverage is provided for orthodontic diagnostic procedures and treatments. This includes surgical, appliance, and
functional therapy with related oral examinations, surgery, extractions, and installation of appliances. Coverage is
available for children up to their 19th birthday. A rider is available that extends this coverage to all persons covered
by the Prime Blue Contract.
There is a lifetime maximum for orthodontic benefits of $2,000 at the 80% payment level and $1,250 at the 50%
payment level.
PRIME BLUE DENTAL
CLASS I - PREVENTIVE SERVICES ALLOWANCES
There is no deductible for Class I. Services are paid at 100% of the maximum allowable amount or charges,
whichever is less. The amount paid is applied toward the calendar year maximum.
Covered services, with a sampling of 2001 payments at 100% of the maximum allowable amount, are shown below.
MAP
Initial and periodic oral exam - two every 12 consecutive months
% Initial oral exam $24.48
% Periodic oral exam $24.48
Dental x-rays
% Intraoral complete series including bitewings - not more than one set
of full mouth x-rays in any consecutive 36 months $57.88
% Bitewing x-rays - 2 films - not more than 2 sets in any 12 month period $15.26
Tests and laboratory exams
% Pulp vitality tests $15.07
Prophylaxis (cleaning) - two every 12 consecutive months
% Adult prophylaxis (age 12 & up) $36.78
% Children=s prophylaxis (age 11 & under) $27.11
Fluoride application - four topical applications of fluoride in 12 consecutive
months for a covered dependent under age 19
% Topical application of fluoride - child $16.34
Emergency treatment for pain
% Palliative treatment - emergency treatment of dental pain, minor procedure $29.73
Sealants - topical application of sealant on a posterior tooth for a covered
dependent under 19 years old - one tooth every 36 months
%Sealant - per tooth $26.78
Preventive periodontal prophylaxis $54.93
Payments may vary from the above depending on the specific services rendered.
Participating dentists will accept payment of Class I services as payment-in-full.
PRIME BLUE DENTAL
CLASS II - BASIC DENTAL SERVICES ALLOWANCES
There is no deductible for Class II. Services are paid at 80% of the maximum allowable amount or charges,
whichever is less. The amount paid is applied toward the calendar year maximum.
Covered services, with a sampling of 2001 payments at 100% of the maximum allowable amount, are shown below.
MAP
Space maintainers for covered dependents under age 19
% Fixed unilateral type $127.90
% Removable bilateral type $192.47
Restorations (fillings)
% Amalgam restoration - two surfaces, permanent tooth $63.00
% Composite resin - two surfaces, anterior $64.52
Extractions
% Simple extraction - single permanent tooth $54.26
% Surgical extraction - complete bony impaction $229.50
Endodontics
% Root canal therapy - anterior tooth $288.70
% Apicoectomy – anterior $285.94
Oral surgery
% Alveoplasty - not in conjunction with extractions, per quadrant $111.75
% Biopsy of oral tissue (hard) $114.76
% General anesthesia when medically necessary-first 30 minutes $136.85
Payments may vary from the above depending on the specific services rendered.
Participating dentists will accept payments of Class II services as payment-in-full.
PRIME BLUE DENTAL
CLASS III - MAJOR DENTAL SERVICES ALLOWANCES
There is a deductible for Class III.
After the deductible is met, services are paid at 80% or 50% (depending on your coverage) of the MAP or charges,
whichever is less. The amount paid is applied toward the calendar year maximum.
Covered services with a sampling of 1998 payments at 100% of the Map are shown below. These allowances are
reviewed yearly.
MAP
Crowns
% Porcelain with semi-precious metal $418.80
% Cast post and core in addition to crown $ 99.47
Inlays and onlays
% Inlay, metallic, two surfaces $300.00
% Onlay, per tooth $374.86
Periodontics
% Gingivectomy or gingivoplasty per quadrant $102.56
% Gingival curettage per quadrant $73.29
% Periodontic scaling and root planing, per quadrant $65.00
Prosthetics
% Complete upper denture $438.48
% Lower partial denture with lingual bar and two clasps, acrylic base $497.32
% Bridge pontic - porcelain fused to semi-precious metal $410.00
% Bridge abutments - porcelain fused to semi-precious metal $425.00
Payments may vary from the above depending on the specific services rendered.
Participating dentists may not accept payments of Class III services as payment-in-full.
PRIME BLUE DENTAL
CLASS IV - ORTHODONTICS
There is no deductible for Class IV.
Services are paid at 80% or 50% (depending on your coverage) of the Maximum Amount Payable (MAP) or
charges, whichever is less. The amount paid is not applied toward the calendar year maximum.
! There is a maximum orthodontic allowance depending on the contract.
! Allowances may vary depending on the specific services rendered.
! Lifetime orthodontic maximums
50% MAP - $1,250
80% MAP - $2,000
HARTWICK COLLEGE
PRIME BLUE DENTAL PROGRAM
(3-TIER)
PACKAGES AVAILABLE
STANDARD OPTION
Class I, II at 100% OF MAP
Class III, IV* at 50% OF MAP
HIGH OPTION
Class I, II at 100% OF MAP
Class III, IV* at 80% OF MAP
$2,000 CALANDER YEAR MAX FOR ORTHO.
HIGHLIGHTS OF BLUE CROSS AND BLUE SHIELD COVERAGE
Blue Cross and Blue Shield of Central New York offers many distinctive advantages which include:
% NATIONALLY RECOGNIZED IDENTIFICATION CARD
% GUARANTEED CONVERSION PRIVILEGES
% PROVIDER DISCOUNTS
% MANY PAID-IN-FULL BENEFITS
% LOCAL SERVICES
% PAPERLESS PROCESSING: DIRECT BILLING BY PARTICIPATING PROVIDER
% MINIMUM ADMINISTRATION BY YOUR GROUP
% COMPLETE CONFIDENTIALITY
% AGGRESSIVE COORDINATION OF BENEFITS DEPARTMENT
% THIRD PARTY BUFFERS
% NO PREMIUM TAXES
% PROTECTION BY NEW YORK STATE INSURANCE DEPARTMENT
Daniel S. Branigan
Sales Consultant
June 27, 2003