Standard Dental Coverage
Current & Former Employee Coverage & Rates for the 2020/21 Plan Year, effective 7/1/2020 through 6/30/2021

Contents
 》Resources
 》Vendor
 》Plan Paid Maximum
 》Deductible
 》Preventive & Diagnostic Services
 》Basic Services
 》Major Services
 》Orthodontic Services
 》Rates

Resources
 》Brochure PDF
 》Video Link
 》Find an In-Network Dentist Link
 》Out-of-Network Claim Reimbursement Form PDF
 》HIPAA Privacy Notice PDF

Vendor
 》BlueCross & BlueShield of Oklahoma (BCBSOK)
 》800.672.2567
 》www.bcbsok.com Link

Coverage
Plan Paid Maximum
 》$1,500 per individual, per plan year
 》Once reached, Member is responsible for 100% of dental claims for the remainder of the plan year

Deductible
 》$50 per individual, per plan year

Preventive & Diagnostic Services
 》Free, twice per plan year
 》Not subject to Deductible
 》Cleaning, Polishing, Bite-Wings X-Rays & Prophylaxis

Basic Services
 》20% Co-Insurance after Deductible
 》Fillings, Simple Extractions, Surgical Removal of Teeth & Root Canals

Major Services
 》50% Co-Insurance after Deductible
 》Crowns, Full or Partial Dentures, Bridge Repairs & Occlusal Guards

Orthodontic Services
 》50% Co-Insurance
 》Not Subject to Deductible
 》For Dependent Children up to Age 26 Only
 》$1,500 Lifetime Maximum

Rates
Current & Former Employee Rates for the 2020/21 Plan Year, effective 7/1/2020 through 6/30/2021
 》38.12Member
 》20.54Child
 》32.66Children
 》48.02Spouse
 》68.56Spouse & Child
 》80.68Spouse & Children