2025 Blue Cross and Blue Shield Service Benefit Plan - FEP Blue Focus
Section 5(g). Dental Benefits
Accidental Injury Benefit
Section 5(g). Dental Benefits
Accidental Injury Benefit
Note: We state whether or not the calendar year deductible applies for each benefit listed in this section.
Benefits Description
Accidental Injury Benefit
We provide benefits for services, supplies, or appliances for dental care necessary to promptly repair injury to sound natural teeth required as a result of, and directly related to, an accidental injury. To determine benefit coverage, we may require documentation of the condition of your teeth before the accidental injury, documentation of the injury from your provider(s), and a treatment plan for your dental care. We may request updated treatment plans as your treatment progresses.
Notes:
You Pay
Treatment of an accidental dental injury within 72 hours:
Preferred: Nothing (no deductible)
Non-preferred professional providers (Participating and Non-participating):
Treatment after the initial 72 hours:
Preferred: 30% of the Plan allowance (deductible applies)
Non-preferred (Participating/Non-participating): You pay all charges
Benefits Description
Accidental Injury Benefit
We provide benefits for services, supplies, or appliances for dental care necessary to promptly repair injury to sound natural teeth required as a result of, and directly related to, an accidental injury. To determine benefit coverage, we may require documentation of the condition of your teeth before the accidental injury, documentation of the injury from your provider(s), and a treatment plan for your dental care. We may request updated treatment plans as your treatment progresses.
Notes:
- An accidental injury is an injury caused by an external force or element such as a blow or fall and that requires immediate attention. Injuries to the teeth while eating are not considered accidental injuries.
- A sound natural tooth is a tooth that is whole or properly restored (restoration with amalgams or resin-based composite fillings only); is without impairment, periodontal, or other conditions; and is not in need of the treatment provided for any reason other than an accidental injury. For purposes of this Plan, a tooth previously restored with a crown, inlay, onlay, or porcelain restoration, or treated by endodontics, is not considered a sound natural tooth.
- We provide benefits for accidental dental injury care in cases of medical emergency when performed by Preferred or Non-preferred providers. See Section 5(d) for the criteria we use to determine if emergency care is required. You are responsible for the applicable cost-share as shown here. If you use a Non-preferred provider, you may also be responsible for any difference between our allowance and the billed amount.
- All follow-up care must be performed and billed for by Preferred providers to be eligible for benefits.
You Pay
Treatment of an accidental dental injury within 72 hours:
Preferred: Nothing (no deductible)
Non-preferred professional providers (Participating and Non-participating):
- Participating: Nothing (no deductible)
- Non-participating: Any difference between our allowance and the billed amount (no deductible)
Treatment after the initial 72 hours:
Preferred: 30% of the Plan allowance (deductible applies)
Non-preferred (Participating/Non-participating): You pay all charges