Blue Cross/Blue Shield of South Carolina
As of January 1, 2010, Avesis administers dental benefits to members of Blue Cross/Blue Shield of South Carolina Medicare Blue Plus and Medicare Blue Private Complete Plus Plans.
If you are a member and need to locate a Participating Provider in your area please use the search link below:
Below you will find an image of the ID card that members will present for services along with a description of the member?s covered benefits.
Office Visit Co-Pay: $10.00 per office visit
Choose Two per year (A or B):
| ADA Code | Description | Limitations | |
|---|---|---|---|
| A | D0120 | Recall Exam | One or two per year |
| B | D0150 | Comprehensive Exam | One per year; (for new patients only-limited to one every 3 years) |
Choose Two per year (A or B):
| ADA Code | Description | Limitations | |
|---|---|---|---|
| A | D1110 | Cleaning ? ages 14 through adult | Two per year |
| B | D1120 | Cleaning ? ages 3-13 | Two per year |
Choose One per year (A or B or C):
| ADA Code | Description | Limitations | |
|---|---|---|---|
| A | D0270/D0272/D0273/D0274 | Bitewing X-rays | One set per year |
| B | D0220 | Single x-ray film and up to 3 additional D0230 |
Total of 4 films per year |
| C | D0210 | Full Mouth X-rays | One set per year; allowed one every 3 years; |
Additional Benefits:
| ADA Code | Description | Limitations | |
|---|---|---|---|
| D4341 or D4342 | Periodontal Scaling | Total of 2 quadrants per year | |
| D5410/D5411/D5421/D5422 | Denture Adjustments | Total of 2 per year |