UHS referral is not required. Coverage in full, up to 6 visits per year. UHS referral is not required. Ambulance charges are covered only with UHS or UR Security prior approval. No UHS referral is required.
Coverage is limited to accidental injury to sound, natural teeth.
Extraction of wisdom teeth is not covered by this contract. Included are replacements required by a change in the patient's physical condition and charges for repair but not replacement due to loss. This is a once in a lifetime benefit. For reimbursement, you must submit a claim form, itemized receipts for purchase of the patches, and a certificate of program completion to BCBS directly. Organized home care provided by a home care agency under contract with Blue Cross is covered for up to 200 visits in a 365 day period, beginning with the date of the first visit.