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