BlueDental Care. Benefit Summary FI315

Transcription

1 BlueDental Care Benefit Summary FI315

2 We can help If you, or someone you re helping, has questions about BlueDental Care, you have the right to get help and information in your language at no cost. To talk to an interpreter, call Spanish French Creole Vietnamese Portuguese Chinese Si usted, o alguien a quien usted está ayudando, tiene preguntas acerca de BlueDental Care, tiene derecho a obtener ayuda e información en su idioma sin costo alguno. Para hablar con un intérprete, llame al Si oumenm oswa yon moun w ap ede gen kesyon konsènan BlueDental Care, se dwa w pou resevwa asistans ak enfòmasyon nan lang ou pale a, san ou pa gen pou peye pou sa. Pou pale avèk yon entèprèt, rele nan Nếu quý vị, hay người mà quý vị đang giúp đỡ, có câu hỏi về BlueDental Care, quý vị sẽ có quyền được giúp và có thêm thông tin bằng ngôn ngữ của mình miễn phí. Để nói chuyện với một thông dịch viên, xin gọi Se você, ou alguém a quem você está ajudando, tem perguntas sobre o BlueDental Care, você tem o direito de obter ajuda e informação em seu idioma e sem custos. Para falar com um intérprete, ligue para 如果您, 或是您正在協助的對象, 有關於插入項目的名稱 BlueDental Care 方面的問題, 您有權利免費以您的母語得到幫助和訊息 洽詢一位翻譯員, 請撥電話在此插入數字 French Si vous, ou quelqu'un que vous êtes en train d aider, a des questions à propos de BlueDental Care, vous avez le droit d'obtenir de l'aide et l'information dans votre langue à aucun coût. Pour parler à un interprète, appelez Tagalog Kung ikaw, o ang iyong tinutulangan, ay may mga katanungan tungkol sa BlueDental Care, may karapatan ka na makakuha ng tulong at impormasyon sa iyong wika ng walang gastos. Upang makausap ang isang tagasalin, tumawag sa Russian Если у вас или лица, которому вы помогаете, имеются вопросы по поводу BlueDental Care то вы имеете право на бесплатное получение помощи и информации на вашем языке. Для разговора с переводчиком позвоните по телефону نا كان لدیك وا ىدل شخص تساعهد ا سي لة بخصصو BlueDental Care كيدلف قحلا يف لوصحلا ىلع ةدعاسملا تامولعملاو Arabic الرورضیة بلغتك من نود ةيا تكلةف. للتحثد مع مرتجم تاصل ب Italian German Korean Polish Gujarati Se tu o qualcuno che stai aiutando avete domande su BlueDental Care, hai il diritto di ottenere aiuto e informazioni nella tua lingua gratuitamente. Per parlare con un interprete, puoi chiamare Falls Sie oder jemand, dem Sie helfen, Fragen zum BlueDental Care, haben, haben Sie das Recht, kostenlose Hilfe und Informationen in Ihrer Sprache zu erhalten. Um mit einem Dolmetscher zu sprechen, rufen Sie bitte die Nummer an. 만약귀하또는귀하가돕고있는어떤사람이 BlueDental Care, 에관해서질문이있다면귀하는그러한도움과정보를귀하의언어로비용부담없이얻을수있는권리가있습니다. 그렇게통역사와얘기하기위해서는 로전화하십시오. Jeśli Ty lub osoba, której pomagasz,macie pytania odnośnie BlueDental Care, masz prawo do uzyskania bezpłatnej informacji i pomocy we własnym języku.aby porozmawiać z tłumaczem, zadzwoń pod numer જ તમ ક તમ મદદ કર રહ ય હ ત મનBlueDental Care વશ પ હ ય, ત તમન મદદ અન તમ ર ભ ષ મ મ હત ક ઇ ખચર વગર મ ળવવ ન અ ધક ર છ. ભ ષય મ આ ન બર પર ફ ન કર, Thai หากค ณ หร อคนท ค ณกาล งช วยเหล อม คาถามเก ยวก บ BlueDental Care ค ณม ส ทธ ท จะได ร บความช วยเหล อและข อม ลในภาษาของค ณได โดยไม ม ค าใช จ าย พ ดค ยก บล าม โทร

3 1557 Non-Discrimination Notice Florida Combined Life Insurance Company, Inc. (FCL) complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. FCL does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. FCL: Provides free aids and services to people with disabilities to communicate effectively with us, such as: Qualified sign language interpreters Written information in other formats (large print, audio, accessible electronic formats, other formats) Provides free language services to people whose primary language is not English, such as: Qualified interpreters Information written in other languages If you need these services, contact If you believe that FCL has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: You can file a grievance in person, by mail or . If you need help filing a grievance, our Civil Rights Coordinator is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at or by mail or phone. U.S. Department of Health and Human Services, 200 Independence Avenue SW, Room 509F, HHH Building, Washington, DC , (TDD) Complaint forms are available at Civil Rights Coordinator Chenal Parkway Little Rock, AR civilrightscoordinator@fclife.com

4 Quality, affordable dental care Welcome. Thank you for considering a BlueDental Care SM plan for your dental coverage needs. Did you know that dental health can have an influence on the development of conditions such as diabetes, coronary artery disease and low-birth-weight, premature babies? An undeniable relationship exists between a healthy mouth and overall good health. That means it s more important than ever for you to receive regular preventive dental care that will help you maintain your good oral health and good health in general. Our dental plans are loaded with features and benefits that offer peace of mind and make going to the dentist easy. As a BlueDental Care member you can look forward to: No deductibles No annual maximum No exclusions for pre-existing conditions No pre-determination of benefits required No claim forms Preventive services at little or no cost to you Low copayments for many dental services. You make the copayment directly to your dentist. See the Benefits Schedule for a sample list of copayment amounts. There s a lot to smile about BlueDental Care gives you access to an extensive network* of select general dentists and specialists throughout Florida, and every member of your family can choose his or her own dentist. To see a list of dentists in the BlueDental Care Prepaid network, visit us at floridabluedental.com. Don t see your dentist in our network? Call us at , press option 1 and then option 2 to nominate him or her. Changing dentists is just as easy. Just call Member Services at , and we ll take care of it. Questions or concerns? Our Customer Service Associates are available to help Monday through Friday, from 8 a.m. to 6 p.m. Just call us at We re here to help. *Networks are comprised of independent contracted dentists.

5 BlueDental Care Benefit Summary for Individual Plan FI315 Your Copayment Amount Diagnostic & Preventive Periodic Oral Evaluation Comprehensive Oral Evaluation X-rays bitewings, two films Cleanings (adult/child) Fluoride Treatment X-rays intraoral/complete series X-rays panoramic film Sealant per tooth $20 Oral Cancer Screening $70 Basic Amalgam Restorations one surface, primary or permanent $30 Resin-based Restorations one surface, anterior $45 Root Canal bicuspid $270 Root Canal molar $390 Periodontal Scaling and Root Planing 4+ teeth per quadrant $85 Full Mouth Debridement to enable eval and diagnosis $80 Extraction, erupted tooth or exposed root $55 Surgical Removal of Erupted Tooth $60 Major Crowns $410+lab* Complete Denture - upper $550+lab* Partial Denture - Resin Based - upper $495+lab* Bridge $410+lab* Teeth Whitening (per arch) $210 Deductible None Annual Maximum Benefit No Maximum Pre-existing Conditions Covered Out-of-Area Emergency Care Up to $100 per member, per year if over 100 miles out of area Out-of-Network Benefits None Covered Procedures Performed by a Specialist** 25% Discount if Participating Specialist NOTE: 1. Not all Participating Dentists perform all listed procedures, including amalgams. Please consult your dentist prior to treatment for availability of services. 2. Some covered Dental Care Services are typically only offered by a specialist (like many oral surgery procedures). 3. When crown and/or bridgework exceeds six units in the same treatment plan, the patient may be charged an additional $75 per unit. 4. Additional exclusions and limitations are listed along with full plan information in your Certificate of Dental Benefits. 5. Copayment amounts for covered procedures are applicable only at the Participating general dentist. If you should need to see a specialist (i.e. Endodontist, Oral Surgeon, Periodontist, Pediatric Dentist), upon identification of yourself as a Florida Combined Life Insurance Co., Inc., member, you will receive a 25% reduction from the participating specialist s usual fee for Covered Dental Care Services performed. Specialist services are only available in areas where the dental plan has a participating specialist. * Services marked with an asterisk (*) also require separate payment of laboratory charges. The laboratory charges must be paid to the participating provider in addition to any applicable copayment for the services. **Usual and Customary Rates

6 BlueDental Care Limitations and Exclusions Coverage is not provided for the following services: No service of any dentist other than a participating general dentist or participating specialist will be covered by company, except out-of-area emergency care as provided in Section XI, Paragraph C of the Certificate. Any procedures not specifically listed as a covered benefit in the Schedule of Benefits. Whenever any contributions or copayments are delinquent, member will not be entitled to receive Benefits, transfer Dental Facilities, or enjoy any of the other privileges of a member in good standing. Any dental treatment started prior to the member s effective date for eligibility of benefits. This does not apply to orthodontic treatment in progress that was covered under the contractholder s prior plan. To be covered under this plan, orthodontic treatment must be shown on your Schedule of Benefits and you must have the subsequent treatment provided by a participating provider. Services which in the opinion of the participating general dentist, participating specialist, or company are not necessary treatment to establish and/or maintain the member s oral health. Any services that are not appropriate or customarily performed for the given condition, do not have uniform professional endorsement, do not have a favorable prognosis, or are experimental or investigational. Any service that is not consistent with the normal and/or usual services provided by the participating general dentist or participating specialist or which in the opinion of the participating general dentist or participating specialist would endanger the health of the member. Any service or procedure which the participating general dentist or participating specialist is unable to perform because of the general health or physical limitations of the member. Procedures, appliances or restorations to change vertical dimension, or to diagnose or treat abnormal conditions of the temporomandibular joint (TMJ); or replacement of lost, missing or stolen appliances. Services performed primarily for cosmetic purposes, unless otherwise listed as covered cosmetic services on your Schedule of Benefits. Services provided by a participating pediatric dentist are limited to children through age seven. Removal of asymptomatic third molars is not covered unless pathology (disease) exists. Examples of symptomatic conditions include decay, cysts, unmanageable periodontal disease, infection, and resorption of adjacent tooth. Frequency and/or age limitations may apply. See your Schedule of Benefits and copayments for details. Workers Compensation 1. If we pay benefits but determine that the benefits were for the treatment of bodily injury or sickness that arose from or was sustained in the course of any occupation or employment for compensation, profit or gain, we have the right to recover that payment. We will exercise our right to recover against you. 2. The recovery rights will be applied even though: a. The Workers Compensation benefits are in dispute or are made by means of settlement or compromise; b. No final determination is made that bodily injury or sickness was sustained in the course of, or resulted from, your employment; c. The amount of Workers Compensation due to medical or health care is not agreed upon or defined by you or the Workers Compensation carrier; or d. Medical or health care benefits are specifically excluded from the Workers Compensation settlement or compromise. 3. You agree that, in consideration for the coverage provided by the contract, we will be notified of any Workers Compensation claim that you make, and you agree to reimburse us as described above. Crowns, inlays, onlays, or veneers for the purpose of: 1. Altering vertical dimension of teeth; 2. Restoration or maintenance of occlusion; 3. Splinting teeth, including multiple abutments; or 4. Replacing tooth structure lost as a result of wear (abrasion, attrition, erosion or abfraction) This benefit summary provides a very brief description of Florida Combined Life s insurance products. This is not an insurance policy and only the actual provisions of an issued policy control. Florida Combined Life s policies set forth the rights and obligations of covered persons and Florida Combined Life. Please be aware that certain limitations and exclusions apply, and certain coverage may reduce or terminate due to age or lack of eligibility. If you enroll for coverage, you will be furnished with a policy or certificate of insurance. Please read your insurance documents carefully. Florida Blue is a trade name of Blue Cross and Blue Shield of Florida, Inc. BlueDental plans are offered through Florida Combined Life Insurance Company, Inc., D/B/A Florida Combined Life, an affiliate of Blue Cross and Blue Shield of Florida, Inc., D/B/A Florida Blue. These companies are Independent Licensees of the Blue Cross and Blue Shield Associations