Blue Cross/Blue Shield of South Carolina
As of January 1, 2011 Avesis administers dental benefits to members of Blue Cross/Blue Shield of South Carolina Medicare Blue Plus and Medicare Blue Saver Plans. If you are a member and need to locate a Participating Provider in your area, please use the search link to the left.
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 |