Return to flip book view

BUSINESS SERVICES CORPORATION D/B/A BENEFIT CHOICESDENTAL PLANSPAGE 1 2024 HIGHMARK BLUESHIELD OF NORTHEASTERN NEW YORK - Small Businesses1 Essential benefits to ensure members receive complete oral health coverage through BlueShield's own dental network.2Flexibility to see out-of-network dentists. Out-of-network services are reimbursed at 100% of the in-network schedule. 3One card for both medical and dental coverage.Plan Name TierRate Per MonthDeductible (Embedded)Out of Pocket MaximumDiagnostic & Preventive (Xrays, Cleaning, Exam)Basic Restorative (Fillings, extractions, perdiodontics, endodontics)Major Restorative Prosthodontics, Crowns, Dentures)Orthodontics (Medically necessary, routine braces not covered)Orthodonic Lifetime MaximumAnnual MaximumBlue Edge Dental F-3WoIndividual Employee/Spouse Parent/Child(ren) Family$28.61 $54.32 $73.16 $109.41$50 per member / $150 family maximum per calendar yearN/A $0 Copayment (covered in full)20% after deductible 50% after deductible 50% coinsurance (pediatric cosmetic orthodontics no cosmetic coverage for adults), subject to lifetime max$1,000 per child per lifetime (Pediatric, routine braces)$2,000 per member per plan yearCan be purchased separately from BlueShield medical. Valid in these counties: Albany-Clinton-Columbia-Essex-Fulton-Greene-Mongomery-Rensselaer-Saratoga-Schenectady-Schoharie-Warren and Washington.Members can receive dental services from a provider who does not participate in the Highmark BSNENY contracted network of providers.Out-of-network services are reimbursed at 100% of the in-network fee schedule minus member's cost-share; the nonparticipating provider may balance bill the member for the remainder.NOTES:Pediatric Dental PPO is now embedded in all medical plans. Simply show your medical card to your dentist.2024CDPHP DELTA DENTAL PPO+ PREMIERE Plan K - Small Business ONLYCARRIER TierRate Per MonthDeductiblesDiagnostic, PreventiveBasic Restorative, Oral Surgery, Endodontics, PeriodonticsMajor Restorative Prosthodontics, Implants, TMJOrthodontics Annual MaximumCDPHP DELTA DENTAL PPO PREMIERE Plan KIndividual Employee/Spouse Parent/Child(ren) Family$45.55 $96.39 $92.11 $146.70$25 per person; $75 per family100% Covered. (Not counted toward annual maximum)80% Covered 50% Covered 0 $1,500 Diagnostic or preventive services do not count toward annual maximum.)CDPHP Pediatric Basic Dental Plan 70Individual (up to 3 children per family)$16.49$65 per person100% Covered 50% Covered 50% Covered50% covered for medical necessity only. 12-month waiting period.Waived for D/PPEDIATRIC DENTAL COVERAGE TO AGE 19: $16.49 per child (aged 18 and under; up to 3) will be added to the premium shown for Parent/Child(ren) or Family rates.

BUSINESS SERVICES CORPORATION D/B/A BENEFIT CHOICESDENTAL PLANSPAGE 2 2024GUARDIAN DENTAL - Small Business or Individual (Sole Proprietor) CARRIER TierRate Per MonthPreventive CareRestoration & Oral Surgery: IN NETWORKRestoration & Oral Surgery: OUT OF NETWORKEndodontics & Periodontics: IN NETWORKEndodontics & PeriodonticsOrthodontics Maximum BenefitGUARDIAN DENTAL PPO Z1 Class 2Individual Employee/Spouse Parent/Child(ren) Family$40.92 $97.25 $107.18 $164.48100% covered 100% coverage after $50 deductible per covered person 80% coverage after $50 deductible per covered person60% coverage after $50 deductible per covered person (6-month Waiting Period)50% coverage after $50 deductible per covered person (6-month Waiting Period)Not available. $1,000 max per covered person per calendar year2024 THE STANDARD Dental Insurance Plan **** NO NEW ENROLLMENT BEING ACCEPTED BY CARRIER ****CARRIER TierPer Month: Albany-Colonie ChamberPer Month: Chamber of Schenectady CountyPer Year BenefitsParticipation RequirementsEnrollment Level Maximum Benefit Preventive Care BASIC 1 * BASIC II ** MAJOR ***Individual Employee/Spouse Parent/Child(ren) Family$52.11 $101.59 $99.00 $148.48$64.60 $125.95 $121.43 $182.78YEAR 1 No Restrictions No Restrictions $1,000 max per covered person per calendar year ^100% 50% coverage after $50 deductible25% coverage after $50 deductibleNot AvailableYEAR 2 No Restrictions No Restrictions $1,000 max per covered person per calendar year 100% 80% coverage after $50 deductible50% coverage after $50 deductible25% coverage after $50 deductibleYEAR 3 No Restrictions No Restrictions $1,000 max per covered person per covered year100% 80% coverage after $50 deductible80% coverage after $50 deductible50% coverage after $50 deductibleINFORMATION SHOWN FOR EXISTING SUBSCRIBERS ONLY. FOR 2024 THE RATES REMAIN THE SAME AS 2023 - NO CHANGES TO ABOVE PLAN.DENTAL NETWORKS: For maximum In-Network Benefits, please use dentists in the following networks - DentalGuard Pref-Syracuse Buy-Up and DentalGuard Pref-Syracuse.THE STANDARD* X-Rays (Intra-oral), Fillings, Sealants. ** Endodontics, Minor Periodontics, Simple Extractions, Minor Restorations. *** Periodontic surgery, Complex Oral Surgery, Major Restoration Prosthodontics (fixed & removed)