BlueCross Dental SM PPO Flexibility. Access. Convenience. Backed by the security of a name trusted for over 75 years, affordable BlueCross Dental plans give you greater control of your dental health with more choices and opportunities to save. Freedom to See Any Dentist BlueCross Dental has one of the largest national dental PPO networks with access in all 50 states. Although you have the freedom to see any dentist you wish, you ll save the most when you visit a BlueCross Dental PPO network provider. No Claim Forms to File Participating providers file claims on your behalf and won t balance bill you. Stability and Security Your diagnostic and preventive services are covered 1 when you visit a network dentist, and coinsurance is applicable for other procedures. No Waiting Periods 3 With BlueCross Dental PPO, it s easy to get quality dental care so you can maintain good oral hygiene and live well. Coverage for Kids Our plans provide coverage for children, including medically necessary orthodontic services. Easy Access on capbluecross.com Find a BlueCross Dental PPO network provider View your benefits, eligibility, and claims Print insurance ID cards Use tools designed to help you live healthy Discounts on Noncovered Services 2 Many participating dentists offer discounts on noncovered services and services received after plan maximums are met. capbluecross.com capitalbluestore.com/blog 1 Deductible may apply. Plan documents describe specific benefits, coverages, and limitations. 2 Not all participating dentists accept the BlueCross Dental fee allowance for noncovered services. Please check with your dentist to determine their status. 3 24-month waiting period is applicable to medically necessary pediatric orthodontic services. Please see plan document or Certificate of Coverage for specific benefits, coverages, and limitations. On behalf of Capital BlueCross, Dominion Dental Services, Inc. assists in the administration of the BlueCross Dental benefits. Dominion Dental is an independent company. On behalf of Capital BlueCross, GRID Dental Corporation provides dental network administration services. GRID Dental Corporation is an independent company. Capital Advantage Insurance Company, Capital Advantage Assurance Company and Keystone Health Plan Central, Capital BlueCross companies, do not discriminate on the basis of race, color, national origin, disability, age, sex, gender identity, sexual orientation or health status in the administration of the plan, including enrollment and benefit determinations. Issued by Capital Advantage Assurance Company, a subsidiary of Capital BlueCross. Independent licensees of the BlueCross BlueShield Association. Communications issued by Capital BlueCross in its capacity as administrator of programs and provider relations for all companies. BCD-30 (11/2014)
Plan Summary
Adult (Age 19 and over) Highlights NETWORK: BlueCross Dental PPO (Individuals) DEDUCTIBLE Per benefit period* BENEFIT PERIOD PROGRAM MAXIMUM When the program maximum is reached, the Member pays 100% until benefit period ends. WAITING PERIODS Adult (Age 19 and over) Member Cost-Sharing $50 per member $150 per family $1,000 per member per benefit period None DENTAL Healthy Dental PPO Plan 1 DIAGNOSTIC AND PREVENTIVE Routine Exams (twice in twelve months) Bitewing X-rays (twice in twelve months) Prophylaxis (twice in twelve months) Palliative Emergency Treatment (acute condition requiring immediate care) Participating Providers Non-participating Providers Year 1 Year 2 Year 3 Year 1 Year 2 Year 3 10% 10% 10% 10% 10% 10% 10% 10% 10% 10% 10% 10% BASIC SERVICES Amalgam and composite fillings 60% 40% 20% 70% 50% 30% Simple Extractions 60% 40% 20% 70% 50% 30% Periapical X-rays (as required) 60% 40% 20% 70% 50% 30% Full Mouth or Panoramic X-rays (once in three years) 60% 40% 20% 70% 50% 30% MAJOR SERVICES Oral Surgery (extraction and oral surgery procedures) 85% 75% 50% 90% 80% 60% Endodontics (procedures for pulpal therapy and root canal 85% 75% 50% 90% 80% 60% filling) Periodontics (treatment to the gums and supporting 85% 75% 50% 90% 80% 60% structures of the teeth; surgical and non-surgical periodontal treatment is covered) General anesthesia (when provided in connection with covered oral surgery or periodontal surgery) 85% 75% 50% 90% 80% 60% Major Restorative (crowns, inlays, onlays) 85% 75% 50% 90% 80% 60% Prosthodontics Procedures for replacement of missing teeth by construction or repair of bridges and partial or complete dentures; prosthetic replacement limited to once in five years) 85% 75% 50% 90% 80% 60% Programs are subject to change. This is not a contract. This information highlights dental benefits when you visit a participating provider and is not intended to be a complete list or complete description of available services. Participating providers agree to accept our allowance as payment in often less than their normal charge. If you visit a non-participating provider, you are responsible for paying the deductible, coinsurance and the difference between the non-participating provider s charges and the allowable amount. Deductibles, coinsurance and copayments under this program are separate from any deductibles, coinsurance and copayments described in other health benefits coverage you may have. *Refer to your Individual Dental Policy and Coverage Schedule for the applicable benefit period. Paper claims may be submitted to the following address: BlueCross Dental; PO Box 1126; Elk Grove Village, IL 60009. Electronic claims may be submitted using Payor ID CBC01. Benefits are issued by Capital Advantage Assurance Company or by Capital Advantage Insurance Company, subsidiary companies of Capital BlueCross. Independent licensees of the BlueCross BlueShield Association. Communications issued by Capital BlueCross in its capacity as administrator of programs and provider relations for all companies. (1/1/2015) Individual Healthy Dental PPO Plan 1
Pediatric (Under Age 19) Highlights NETWORK: BlueCross Dental PPO (Individuals) DEDUCTIBLE Per benefit period* Deductible waived for diagnostic and preventive. OFFICE VISIT COPAYMENT Participating Providers DENTAL Healthy Dental PPO Plan 1 Pediatric (Under age 19) Member Cost-Sharing $75 per member $10 per visit Non-participating Providers OUT OF POCKET MAXIMUM When the out-of-pocket maximum is reached, benefits are paid at 100% of the allowed amount until the benefit period ends. $350 per member $700 per family None BENEFIT PERIOD PROGRAM MAXIMUM When the program maximum is reached, the Member pays 100% until the end of the benefit period ends. None None DIAGNOSTIC AND PREVENTIVE (Deductible Waived) Routine Exams (once in six months) 20% X-rays 20% Periapical X-rays (as required) Bitewing X-rays (once in six months) Full Mouth or Panoramic X-rays (once in five years) Fluoride Treatments (once in six months) 20% Prophylaxis (once in six months) 20% Sealants (permanent molars; one per tooth in any three year period) 20% Space Maintainers (one in twenty-four months, per arch) 20% Palliative Emergency Treatment (acute condition requiring immediate care) 20% BASIC SERVICES Amalgam and composite fillings 50% 70% Simple Extractions 50% 70% MAJOR SERVICES Oral Surgery (extraction and oral surgery procedures) 50% 70% Endodontics (procedures for pulpal therapy and root canal filling) 50% 70% Periodontics (treatment to the gums and supporting structures of the teeth; surgical and non-surgical 50% 70% periodontal treatment is covered) General anesthesia (when provided in connection with a covered procedure) 50% 70% Major Restorative (crowns, inlays, onlays; one per tooth per five year period) 50% 70% Prosthodontics Procedures for replacement of missing teeth by construction or repair of bridges and partial or complete dentures; prosthetic replacement limited to once in five years Implant surgical placement and removal; implant supported prosthetics, including repair and recementation 50% 70% ORTHODONTICS Pediatric Orthodontic Treatment (medically necessary); 24 month waiting period 50% Not covered ORTHODONTICS LIFETIME MAXIMUM Lifetime maximum (medically necessary) None N/A Programs are subject to change. This is not a contract. This information highlights dental benefits when you visit a participating provider and is not intended to be a complete list or complete description of available services. Participating providers agree to accept our allowance as payment in often less than their normal charge. If you visit a non-participating provider, you are responsible for paying the deductible, coinsurance and the difference between the non-participating provider s charges and the allowable amount. Deductibles, coinsurance and copayments under this program are separate from any deductibles, coinsurance and copayments described in other health benefits coverage you may have. *Refer to your Individual Dental Policy and Coverage Schedule for the applicable benefit period. Paper claims may be submitted to the following address: BlueCross Dental; PO Box 1126; Elk Grove Village, IL 60009. Electronic claims may be submitted using Payor ID CBC01. Benefits are issued by Capital Advantage Assurance Company or by Capital Advantage Insurance Company, subsidiary companies of Capital BlueCross. Independent licensees of the BlueCross BlueShield Association. Communications issued by Capital BlueCross in its capacity as administrator of programs and provider relations for all companies. (1/1/2015) Individual Healthy Dental PPO Plan 1
Coverage Schedule
Issued By CAPITAL ADVANTAGE ASSURANCE COMPANY Harrisburg, PA A Capital BlueCross company and independent licensee of the BlueCross and BlueShield Association Healthy Dental PPO Plan 1 Coverage Schedule for Adult Services - age 19 and over - Benefit Coverage Plan Coverage In-Network Out-of Network Year 1st 2nd 3rd 1st 2nd 3rd Class I 100% 100% 100% 90% 90% 90% Class II 40% 60% 80% 30% 50% 70% Class III 15% 25% 50% 10% 20% 40% Class IV 0% 0% 0% 0% 0% 0% Endo/Perio Class III Benefi ts Class III Benefi ts Annual Deductible In-Network Out-of-Network Single Adult $50 $50 Three or More Adults $150 $150 Applies to all Yes Yes Benefi ts Maximums In-Network Out-of-Network Annual $1,000 $1,000 * Annual Maximum applies to Class I, Class II and Class III Benefi ts. Waiting Periods In-Network Out-of-Network Class I NONE NONE Class II NONE NONE Class III NONE NONE Class IV N/A N/A Deductible is combined for all services for each calendar year per adult Member maximum $150 for adult Members. Services may be received from any licensed dentist. If course of treatment is to exceed $300, prior review is requested. BCDPA15SB1INDFAMEHB BlueCross Dental Processing Center 115 South Union Street, Suite 300 Alexandria, VA 22314 (800) 613-2624 PID 2352
Plan will pay the Participating Dentist the lesser of the dentist s negotiated fee or the Maximum Allowable Charge and generally pays a Nonparticipating Dentist the Maximum Allowable Charge for dental procedures and services as shown below, after any required Annual Deductible (services also subject to benefi t coverage percentage). For Out-of-Network Benefi ts, Member is responsible for any amount charged which exceeds the Maximum Allowable Charge per procedure. Class I. Diagnostic and Preventive Services Include: 1. Two evaluations per Calendar Year including a maximum of one comprehensive evaluation 2. One emergency or problem focused exam (D0140) per Calendar Year 3. Two prophylaxis (cleaning, scaling and polishing teeth) per Calendar Year 4. Bitewing x-rays, 2 per Calendar Year 5. Emergency palliative treatment (only if no services other than exam and x-rays were performed on the same date of service) Class II. Basic Services, Include: 1. Simple extraction of teeth 2. Amalgam and composite fi llings (restorations of mesiolingual, distolingual, mesiobuccal, and distobuccal surfaces considered single surface restorations) 3. Periapical x-rays 4. One diagnostic x-ray, or panoramic per 36 months 5. Pin retention of fi llings (multiple pins on the same tooth are allowable as one pin) 6. Antibiotic injections administered by a dentist Class III. Major Services: 1. Oral surgery, including postoperative care for: a. Removal of teeth, including impacted teeth b. Extraction of tooth root c. Alveolectomy, alveoplasty, and frenectomy d. Excision of periocoronal gingiva, exostosis, or hyper plastic tissue, and excision of oral tissue for biopsy e. Reimplantation or transplantation of a natural tooth f. Excision of a tumor or cyst and incision and drainage of an abscess or cyst 2. Endodontic treatment of disease of the tooth, pulp, root, and related tissue, limited to: a. Root canal therapy (not covered if pulp chamber was opened before effective date of coverage) b. Pulpotomy c. Apicoectomy d. Retrograde fi llings 3. Periodontic services, limited to: a. Two periodontal cleanings following surgery per Calendar Year (D4341 is not considered surgery) b. One root scaling and planing per quadrant of mouth per 6 months c. Occlusal adjustment performed with covered surgery d. Gingivectomy and gingival curettage e. Osseous surgery including fl ap entry and closure f. Pedicle or free soft tissue graft g. One appliance (night guards) per 5 years h. One mouth debridement per lifetime 4. One study model per 36 months 5. Crown build-up for non-vital teeth 6. Recementing bridges, inlays, onlays and crowns 7. One repair of dentures or fi xed bridgework per 24 months 8. General anesthesia and analgesic, including intravenous sedation, in conjunction with covered oral surgery, periodontal surgery 9. Restoration services, limited to: a. Gold or porcelain inlays, onlays, and crowns for tooth with extensive caries or fracture that is unable to be restored with an amalgam or composite fi lling b. Replacement of existing inlay, onlay, or crown, after 5 years of the restoration initially placed or last replaced (will not apply if replacement is necessary due to the extraction of functioning natural teeth after the effective date of coverage) c. Post and core in addition to crown when separate from crown for endodontically treated teeth, with a good prognosis endodontically and periodontally 10. Prosthetic services, limited to: a. Initial placement of dentures or fi xed bridgework (including acid etch metal bridges) b. Replacement of dentures or fi xed bridgework that cannot be repaired after 5 years from the date of last placement c. Addition of teeth to existing partial denture d. One relining or rebasing of existing removable dentures per 24 months (only after 12 months from date of last placement) Class IV. Orthodontia Services: Not Covered Diagnostic, active and retention treatment to include removable fi xed appliance therapy and comprehensive therapy Adult Plan Exclusions: 1. Services which are covered under worker s compensation, employer s liability laws or the Pennsylvania Motor Vehicle Financial Responsibility Law. 2. Services which are not necessary for the patient s dental health. 3. Reconstructive, plastic, cosmetic, elective or aesthetic dentistry. 4. Oral surgery requiring the setting of fractures and dislocations. 5. Services with respect to malignancies, cysts or neoplasms, hereditary, congenital, mandibular prognathism or development malformations where such services should not be performed in a dental offi ce. 6. Dispensing of drugs. 7. Hospitalization for any dental procedure. 8. Treatment required for conditions resulting while on active duty as a member of the armed forces of any nation or from war or acts of war, whether declared or undeclared. 9. Implant removal or the replacement of dentures, bridges, inlays, onlays or crowns that can be repaired or restored to normal function. 10. Diagnosis or treatment of Temporomandibular Disorder (TMD) syndromes, problems and/or occlusal disharmony. 11. Elective surgery including, but not limited to, extraction of nonpathologic, asymptomatic impacted teeth. 12. Services not listed as covered. 13. Implants and related services; replacement of lost, stolen or damaged prosthetic or orthodontic appliances; athletic mouthguards; precision or semi-precision attachments; denture duplication; sealants; space maintainers; fl uoride; periodontal splinting of teeth. 14. Services for increasing vertical dimension, replacing tooth structure lost by attrition, and correcting developmental malformations and/or congenital conditions. 15. Procedures that in the opinion of the Plan are experimental or investigative in nature because they do not meet professionally recognized standards of dental practice and/or have not been shown to be consistently effective for the diagnosis or treatment of the Member s condition. 16. Treatment of cleft palate, malignancies or neoplasms. 17. Any service or supply rendered to replace a tooth lost prior to the effective date of coverage. This exclusion expires after 36 months of Member s continuous coverage under the plan. Some Participating Dentists have agreed to bill members the Plan s allowable amount or the provider s charge, whichever is less, for noncovered services or services in excess of benefi t lifetime maximums or benefi t period maximums. Members should check with their provider to determine applicability.
Healthy Dental PPO Plan 1 Coverage Schedule for Pediatric Services - under age 19 - Plan Coverage Office Visit Copay In-Network Out-of-Network Amount Per Visit $10 $10 Benefit Coverage In-Network Out-of-Network Class I 100% 80% Class II 50% 30% Class III 50% 30% Class IV 50% 0% Endo/Perio Class III Benefi ts Class III Benefi ts Annual Deductible In-Network Out-of-Network Per Child $75 $75 Applies to all No, Waived on No, Waived on Benefi ts Class I Benefits Class I Benefits Out-of-Pocket Maximums* In-Network Out-of-Network Single Child $350 N/A Two or More Children $700 N/A * Annual Out-of-Pocket Maximum applies to all covered services for medically necessary treatment. Waiting Periods: There are no waiting periods with the exception of medically necessary orthodontia, which requires a 24-month waiting period. Deductible is combined for all covered services for each calendar year per pediatric Member. Services may be received from any licensed dentist. If course of treatment is to exceed $300, prior review is requested.
Plan will pay the Participating Dentist the lesser of the dentist s negotiated fee or the Maximum Allowable Charge and generally pays a Nonparticipating Dentist the Maximum Allowable Charge for dental procedures and services as shown below, after any required Annual Deductible (services also subject to benefit coverage percentage). For Out-of-Network Benefits, Member s Personal Representative is responsible for any amount charged which exceeds the Maximum Allowable Charge per procedure. Class I. Diagnostic and Preventive Services: 1. One (1) evaluation (D0120, D0140, D0160 or D0180) per six (6) months, per patient. D0150 limited to one (1) per 12 months 2. One (1) prophylaxis (D1110 or D1120) per six (6) months, per patient 3. One (1) fl uoride treatment is covered every six (6) months, per patient 4. Bitewing x-rays, one (1) set per six (6) months, starting at age two (2) 5. Periapical x-rays (not on the same date of service as a panoramic radiograph) 6. One (1) mouth x-ray or panoramic fi lm, starting at age six (6), per 60 months; maximum of one (1) set of x-rays per offi ce visit 7. One (1) space maintainer (D1515 or D1525) per 24 months, per patient, per arch to preserve space between teeth for premature loss of a primary tooth (does not include use for orthodontic treatment) 8. One (1) sealant per tooth, per 36 months (limited to occlusal surfaces of posterior permanent teeth without restorations or decay) 9. Emergency palliative treatment (only if no services other than exam and x-rays were performed on the same date of service) Class II. Basic Services: 1. Simple extraction of teeth 2. Amalgam and composite fi llings (restorations of mesiolingual, distolingual, mesiobuccal, and distobuccal surfaces considered single surface restorations), per tooth, per surface every 36 months 3. Pin retention of fi llings (multiple pins on the same tooth are allowable as one (1) pin) 4. Occlusal guard, analysis and limited/complete adjustment, one (1) in 12 months for patients 13 and older, by report Class III. Major Services: 1. Oral surgery, including postoperative care for: a. Removal of teeth, including impacted teeth b. Extraction of tooth root c. Alveolectomy, alveoplasty, and frenectomy d. Excision of periocoronal gingiva, exostosis, or hyper plastic tissue, and excision of oral tissue for biopsy e. Reimplantation or transplantation of a natural tooth f. Excision of a tumor or cyst and incision and drainage of an abscess or cyst 2. Endodontic treatment of disease of the tooth, pulp, root, and related tissue, limited to: a. Root canal therapy, one (1) per lifetime, per patient, per permanent tooth; one (1) retreatment of previous root canal therapy per lifetime, not within 24 months when done by same dentist or dental offi ce b. Pulpotomy c. Apicoectomy d. Retrograde fi llings, per root per lifetime 3. Periodontic services, limited to: a. Two (2) periodontal cleanings, in addition to adult prophylaxis, per plan year, within 24 months after defi nitive periodontal therapy b. One (1) root scaling and planing per 24 months, per patient, per quadrant c. Gingivectomy and gingival curettage, one (1) per 36 months, per patient, per quadrant d. Osseous surgery including fl ap entry and closure, one (1) per 36 months, per patient, per quadrant e. One (1) pedicle or free soft tissue graft per site, per lifetime f. One (1) mouth debridement per lifetime 4. One (1) study model per 36 months 5. General anesthesia and analgesic (only when provided in connection with a covered procedure(s) when determined to be medically or dentally necessary for documented handicapped or uncontrollable patients or justifi able medical or dental conditions), including intravenous and nonintravenous sedation with a maximum of 60 minutes of services (general anesthesia is not covered with procedure codes D9230, D9241 or D9242; intravenous conscious sedation is not covered with procedure codes D9220 or D9221; non-intravenous conscious sedation is not covered with procedure codes D9220 or D9221; requires a narrative of medical necessity be maintained in patient records 6. Restoration services, limited to: a. Cast metal, stainless steel, porcelain/ceramic, all ceramic and resinbased composite onlay, or crown for teeth with extensive caries or fracture that is unable to be restored with an amalgam or composite fi lling, one (1) per 60 months from the original date of placement, per permanent tooth, per patient. b. Post and core in addition to crown when separate from crown for endodontically treated teeth, with a good prognosis endodontically and periodontally c. Sedative fi lling d. Post removal e. Crown build-up for non-vital teeth f. Inlay, onlay and veneer repair g. Repair of crowns limited to two (2) times per plan year and five (5) total per fi ve (5) years in combination with repair of dentures and bridges 7. Prosthetic services, limited to: a. Initial placement of dentures b. Replacement of dentures that cannot be repaired after fi ve (5) years from the date of last placement c. Addition of teeth to existing partial denture d. One (1) relining or rebasing of existing removable dentures per 24 months, only after 24 months from the date of last placement unless an immediate prosthesis replacing at least three (3) teeth e. Repair of dentures and bridges, limited to two (2) times per year and fi ve (5) total per fi ve (5) years in combination with repair of crowns f. Construction of bridges, replacement limited to one (1) per 60 months g. Implants and related services; replacement of implant crowns limited to one (1) in 60 months. Class IV. PRE-AUTHORIZATION REQUIRED *MEDICALLY NECESSARY* Orthodontia Services: Diagnostic, active and retention treatment to include removable fi xed appliance therapy and comprehensive therapy; Orthodontia services are only provided for severe, dysfunctional, handicapping malocclusion. A 24-month waiting period applies to medically necessary orthodontia. Pediatric Plan Exclusions 1. Services which are covered under worker s compensation, employer s liability laws or the Pennsylvania Motor Vehicle Financial Responsibility Law. 2. Services which are not necessary for the patient s dental health. 3. Cosmetic, elective or aesthetic dentistry except as required due to accidental bodily injury to sound natural teeth. 4. Oral surgery requiring the setting of fractures or dislocations. 5. Services with respect to malignancies, cysts or neoplasms, hereditary, congenital, mandibular prognathism or development malformations where such services should not be performed in a dental offi ce. 6. Dispensing of drugs. 7. Hospitalization for any dental procedure. 8. Treatment required for conditions resulting from major disaster, epidemic, war, acts of war, whether declared or undeclared, or while on active duty as a member of the armed forces of any nation. 9. Replacement due to loss or theft of prosthetic appliance. 10. Services related to the treatment of TMD (Temporomandibular Disorder). 11. Elective surgery including, but not limited to, extraction of non-pathologic, asymptomatic impacted teeth. The prophylactic removal of these teeth for medically necessary orthodontia services may be covered subject to review. 12. Services not listed as covered. 13. Replacement of dentures, inlays, onlays or crowns that can be repaired to normal function. 14. Services for increasing vertical dimension, replacing tooth structure lost by attrition, and correcting developmental malformations and/or congenital conditions except if the developmental malformation and/or congenital conditions cause severe, dysfunctional handicapping malocclusion that requires medically necessary orthodontia services. 15. Procedures, that in the opinion of the Plan, are experimental or investigative in nature because they do not meet professionally recognized standards of dental practice and/or have not been shown to be consistently effective for the diagnosis or treatment of the Member s condition. 16. Treatment of cleft palate (if not treatable through orthodontics), anodontia, malignancies or neoplasms. 17. Orthodontics is only covered if medically necessary as determined by the Plan. There is a 24-month waiting period for Medically Necessary Orthodontia. The Invisalign system and similar specialized braces are not a covered benefit. Patient co-insurance will apply to the routine orthodontic appliance portion of services only. Additional costs incurred will become the patient s responsibility. Some Participating Dentists have agreed to bill members the Plan s allowable amount or the provider s charge, whichever is less, for non-covered services or services in excess of benefi t lifetime maximums or benefi t period maximums. Members should check with their provider to determine applicability.