RXINSIDER 2025
BCBS Dental FlexChoice Certi�ed 873C Plan Summary
Dental Care Services
Deductibles
Employee
Family
Annual Maximum Per Member
$50
$150
$1,500
Diagnostic and Preventative
Plan Pays
Up to Age 19
Age 19 and Over
• Oral Evaluations
• Cleanings
• Fluoride Treatment
• X-rays
• Sealants
100%
100%
100%
100%
100%
100%
100%
Not Covered
100%
Not Covered
Basic Dental
• Fillings
• Simple Extractions
• Root Canal Therapy
• Braces (Medically Necessary)
• Braces (Elective)
100% After Deductible
100% After Deductible
100% After Deductible
50% After Deductible
Not Covered
100% After Deductible
100% After Deductible
100% After Deductible
Not Covered
Not Covered
BCBS Dental Care Bene�ts