Plan Coverage
1. Standard Plan
This plan covers 80% of the eligible expenses up to the following maximum benefit limits. Blue Cross will reimburse 80% of the eligible expenses incurred, and customer will have to bear the remaining 20%.
Benefit Items Maximum Benefit Limit (HK$)
1. X-rays required prior to performance of dental service
a)
Single film
 Per film 120
b)
Additional film
 Per film 110
2. Abscesses
a)
Non-surgical
 Per abscess 460
b)
Surgical
 Per abscess 900
3. Fillings
a)
Amalgam
 Per tooth 900
b)
Composite (e.g. resin)
 Per tooth 600
c)
With acid etch
 Per tooth 980
4. Pins for Cusp Restoration
a)
First pin
 Per pin 320
b)
Subsequent pin for the same tooth
 Per pin 165
5. Root Canal Treatment Per tooth 3,600
6. Extractions
a)
Surgical or non-surgical extraction (except item no. 6b)
 Per tooth 600
b)
Surgical extraction of an impacted wisdom tooth
 Per tooth 2,800
7. Apicoectomy
Anterior teeth Per tooth 2,800
8. Dentures (caused by accident only)
a)
Both full sets (upper and lower)
 11,000
b)
One full set (upper or lower)
 5,600
c)
Partial set
 
i.
Per preparation plate
 5,600
 
ii.
Per denture
 380
9. Medication for dental treatments as prescribed by a dentist Per policy year 600
10. Routine Oral Examination
Scale & polish and prophylaxis (twice per policy year)
100% Reimbursement 		Per visit 600
Overall Maximum Benefit Limit Per Policy Year (exclude cost of dentures) 12,500


2. Executive Plan
This plan covers 100% of eligible expenses up to the following maximum benefit limits.
Benefit Items Maximum Benefit Limit (HK$)
Executive Plan covers benefit items 1 to 21, except item 8 which is replaced by item 15.
11. Periodontal Surgery
a)
Subgingival curettage (per treatment)
 1,100
b)
Gingivectomy (6 teeth or above in total, or per quadrant)
 2,300
c)
Gingivectomy (5 teeth or below in total)
 820
12. Apicoectomy (Molar & Pre-molar) Per tooth 3,600
13. Gold Inlay
a)
One surface
 Per tooth 3,000
b)
Two surfaces
 Per tooth 3,800
c)
Three surfaces
 Per tooth 5,000
14. Crowns and Bridges
a)
Acrylic jacket crown
Per crown or bridge 2,700
b)
Porcelain jacket crown
 Per crown or bridge 3,800
c)
Bridgework
 Per crown or bridge 3,600
15. Dentures (caused by accident or dental condition)
a)
Both full sets (upper & lower)
 11,000
b)
One full set (upper or lower)
 5,600
c)
Partial set
 
i.
Per preparation plate (caused by accident)
 5,600
 
ii.
Per preparation plate (caused by dental condition)
 2,500
 
iii.
Per denture
 380
16. Accident Emergency Treatment
a)
Include X-rays, temporary pain relief, temporary fillings, medication, incision and drainage of abscess
 Per accident 820
b)
Non-working hours treatment
 Per accident 1,900
17. Partial Soft-tissue Impaction Per accident/dental condition 1,100
18. Complete Soft-tissue Impaction Per accident/dental condition 2,800
19. Bony Impaction Per accident/dental condition 1,700
20. Orthodontic Treatment
(necessitated by threat to the health of the insured and recommended as medically necessary by qualified physician or dentist) 		Per policy year 9,200
21. Panoramic Film Per policy year 380
Overall Maximum Benefit Limit Per Policy Year (exclude cost of dentures) 24,000

Remark: For details of notes 3 & 4, please refer to “Points to Note”
Notes:
1. The above information is for reference only. Please refer to policy for the exact terms and conditions and the full list of policy exclusions.
2. Should there be any discrepancy between the English and the Chinese versions of the above information, the English version shall apply and prevail.
3. The above product(s) is/are offered for sale in Hong Kong only and is/are underwritten by Blue Cross (Asia-Pacific) Insurance Limited, an authorised insurer in Hong Kong.
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