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Dental Benefit

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How we pay Dental Blue PPO How to File a claim Dental Blue POS

Welcome to the Blue Cross and Blue Shield Dental Blue and to Dental Blue POS.

Dental Blue POS is a dental plan designed to manage the cost of dental services. Using preferred dentists will minimize your out–of–pocket expenses.

Please note: This is a brief description of your Dental Blue POS plan. It should be used only as a guide. It does not contain complete details of the plan. The Dental Blue POS Subscriber Certificate, any applicable riders, and Orthodontic Endorsement define the terms and conditions, including limitations and exclusions, of your dental care coverage in greater detail. If questions arise concerning coverage, the certificates riders, and Orthodontic Endorsement will govern. You can get copies of the certificate, riders, and Orthodontic Endorsement from Customer Service or your plan sponsor.

Your Dentist
If you already have a dentist and you want to know if he or she is in the Dental Blue PPO network, you may call the dentist, call Customer Service at 1–800–217–7878 or look in Our Dental Blue PPO Directory of Providers.

Your Benefits
Your benefits are subject to the co–insurance and benefit maximums chosen by your group. Payments are based on whether or not you receive services from an in–network or out–of–network provider. Many covered services have specific time or age limits associated with them. For example:

• We will pay for cleanings only once each six months
• Fluoride treatments are only for members under age 19
• Major restorative services such as crowns, bridges, and dentures have a 60–month time limit, etc. This means you will only receive benefits if five years has elapsed since the last time your tooth was restored

How We Pay Dental Blue PPO

Dentists
Payments are based on the Dental Blue PPO preferred fee schedule for covered services. Dentists who are in the Dental Blue PPO network agree to accept the preferred fee schedule allowance, in addition to your co–insurance as payment in full. You are responsible for your co–insurance and all charges beyond your calendar–year benefit maximum.

How We Pay Dental Blue Dentists
Payments are based on the usual and customary charge for covered services. Dentists who are in the Dental Blue network agree to accept your plan's payment, in addition to your co–insurance as full payment. You will be responsible for your co–insurance and all charges beyond your calendar– year benefit maximum. This provision does not apply to emergency care services.

Orthodontic Benefits

• Payments are provided in the same manner as other dental services. You are responsible for your co–insurance and all benefits beyond your lifetime benefit maximum.
• The lifetime benefit maximum is not part of your calendar–year benefit maximum; it is a one–time benefit amount payable towards orthodontic services.
• We will begin payment the day your appliances are placed. If your orthodontic treatment began before you were covered, we will pay a monthly fee for your remaining orthodontic visits until either your braces are removed or the lifetime benefit maximum is exhausted whichever comes first.

Predetermination of Benefits

• If your dentist expects that your dental treatment will involve a series of covered services that will cost more than $250, he or she should send a copy of the "treatment plan" to us before services are rendered. A treatment plan is a detailed description of the procedures that the dentist plans to perform and includes an estimate for the charges for each service.
• Your dentist should also submit a treatment plan for periodontal, denture, crown, and bridge services before any services arc tendered, even if he or she expects the cost to be $250 or less.
• Once we review the treatment plan, we'll notify you and your dentist of the benefits available for those services.

Remember, the payment estimate is based on the amount of your calendar–year benefit maximum at the time & receive and review the estimate. (The actual payment may differ if your available calendar–year benefit maximum has changed.)

Waiting Periods

• You are covered, without a waiting period, from the date you enroll in the plan.

Memberships

• An individual membership covers one person only – the "subscriber."
• A family membership covers the Subscriber, spouse, unmarried dependent children under age 19, and children of covered unmarried dependents. When a dependent child marries or turns 19, coverage under his or her parent's family membership ends. A disabled child over age 19 may qualify for continued coverage under a family membership. We must be notified before the child's 19th birthday.
• Unmarried dependent children who are full–time students are covered under a family membership until age 23. Be sure your plan sponsor knows your dependent is a full–time student.
• Under federal law, your coverage and your dependents' coverage may be continued under certain circumstances (e.g., you leave your job or your dependent turns 19). Contact your plan sponsor for details.
• There are no conversion privileges under this dental plan. Your coverage ends on the date you are no longer covered through your group.