Benefits Open Enrollment

*College contribution is 75% of single plan premium with same dollar contribution to family premium. For less than full-time employees, College contribution is based on a sliding scale (similar to health insurance).

Blue Cross / Blue Shield Dental Blue Summary (PDF)

Blue Cross / Blue Shield Dental Max (rollover benefit) (PDF)

SERVICES	Percentage Paid
Preventive Services*	100%

Diagnostic:

One complete initial oral exam, including dental history and charting of teeth and supporting structures
Full Mouth x-rays, seven or more films, or panoramic x-ray with bitewing x-rays once each 60 months
Bitewing x-rays once each 6 months
Single tooth x-rays as needed
Study models and casts used in planning treatment once each 60 months
Periodic or routine oral exams once each 6 months
Emergency exams

Preventative:

Routine cleaning, scaling, and polishing of the teeth once each 6 months
Fluoride Treatments - 1 every 6 months for members under the age of 19
Sealants on permanent pre-molar and molar surfaces (members under age 14)
Space Maintainers needed due to premature tooth loss (members under age 19)

Basic Restorative Services

80% after deductible

Restorative:

Amalgam (silver) fillings (limited to one filling for each tooth surface in a 12 month period
Composite resin fillings on a single-surface back tooth (bicuspids and molars) in a 12 month period. (Benefits will continue to be provided for amalgam fillings toward the cost of multiple surface composite resin fillings. You pay any balance.)
Pin retention for fillings.
Stainless steel crowns on baby teeth and on first permanent adult molars (members under age 16)

Oral Surgery:

Tooth extraction
Root removal
Biopsies

Periodontics (gum and bone):

Periodontic scaling and root planing once per quadrant each 24 months
Periodontal surgery once per quadrant each 36 months
Periodontal maintenance following active periodontal therapy once each 3 months.

Endodontics (roots and pulp):

Root canal therapy (permanent teeth, once per lifetime per tooth
Retreatment root cananl therapy on permanent teeth, once in a lifetime for each tooth
Therapeutic pulpotomy on primary or permanent teeth (members under age 16)
Other endodontic surgery to treat or remove the dental root.

Prosthetic Maintenance:

Repair of partial or complete dentures, crowns, and bridges once each 12 months
Adding teeth to an existing complete or partial denture
Rebase or reline of dentures once each 36 months
Recementing of crowns, inlays, onlays, and fixed bridgework once each 12 months

Other Services:

Occlusal adjustments once each 24 months
Services to treat root sensitivity
Emergency dental care to treat acute pain or to prevent permanent harm to a member
General anesthesia when administered in conjunction with covered surgical services

Major Restorative

50% after deductible

Prosthodontics (teeth replacement):

Complete or partial dentures (including services to fabricate, measure, fit, and adjust them) once each 60 months for each arch
Fixed bridges (including services to fabricate, measure, fit, and adjust them) once each 60 months for each tooth
Replacement of dentures and bridges once each 60 months when existing appliance can't be made serviceable
Adding teeth to an existing bridge
Temporary partial dentures to replace any of the six upper or six lower front teeth (only covered if they are installed immediately following the loss of teeth and during the period of healing)

Major Restorative (members age 16 or older):

Crowns, once each 60 months for each tooth
Metallic, porcelain, and composite resin inlays. Benefits are provided for an amalgam filling toward the cost of a metallic, porcelain, or composite resin inlay, once each 60 months for each tooth. You pay any balance.
Metallic, porcelain, and composite resin onlays, once each 60 months for each tooth
Replacement of crowns, once each 60 months for each tooth.
Replacement of metallic, porcelain, and composite resin inlays. Benefits are provided for an amalgam filling toward the cost of a metallic, porcelain, or composite resin inlay, once each 60 months for each tooth. You pay any balance.
Replacement of metallic, porcelain, and composite resin onlays, once each 60 months for each tooth.
Post and core or crown buildup, once each 60 months for each tooth
Single tooth dental endosteal implants (the fixture and abutment portion) in addition to the allowance for the crown for the implant once each 60 month period, when the implant replaces permanent teeth through the second molars (members age 16 and older)

Human Resources
Mount Holyoke College, 50 College Street South Hadley, MA 01075-1453
Phone: 413-538-2503