Dental Blue Freedom For Retired Members

Dental Blue Freedom For Retired Members

 

This section provides you with a description of your benefits while you are enrolled under Dental Blue Freedom. You should read this booklet to familiarize yourself with the main provisions of Dental Blue Freedom and keep it handy for reference.

Blue Cross and Blue Shield has been designated by your plan sponsor to provide administrative services to Dental Blue Freedom, such as claims processing, case management and other services, and to arrange for a network of dentists whose services are covered by Dental Blue Freedom. The Blue Cross and Blue Shield customer service office can help you understand the terms of Dental Blue Freedom and what you need to do to get your maximum benefits.

Blue Cross and Blue Shield of Massachusetts, Inc. (Blue Cross and Blue Shield) is an independent corporation operating under a license from the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans, (the “Association”) permitting Blue Cross and Blue Shield to use the Blue Cross and Blue Shield Service Marks in the Commonwealth of Massachusetts. Blue Cross and Blue Shield has entered into a contract with the plan sponsor on its own behalf and not as the agent of the Association.

You are covered under Dental Blue Freedom. Your dental coverage under Dental Blue Freedom consists of a Dental Blue PPO plan and a Dental Blue plan. Dental Blue Freedom is a non-insured, self-funded benefits plan and is financed by contributions by your group and its enrolled employees. (For details concerning your group’s contributions, contact your plan sponsor.) An organization has been designated by your plan sponsor to provide administrative services to Dental Blue Freedom, such as claims processing, case management and other services, and to arrange for a network of dentists whose services are covered by Dental Blue Freedom. The name and address of this organization is:

Blue Cross and Blue Shield of Massachusetts, Inc.
Landmark Center
401 Park Drive
Boston, Massachusetts 02215-3326

Dental Blue Freedom benefits are provided by your group on a self-funded basis. Blue Cross and Blue Shield is not an underwriter or insurer of the benefits provided by Dental Blue Freedom.

This Dental Blue Freedom booklet along with all riders that are part of your Dental Blue Freedom Benefit Description provide you with a description of your benefits while you are enrolled in Dental Blue Freedom. You should read this booklet to familiarize yourself with the main provisions and keep it handy for reference. The words in italics have special meanings and are described in Part 1. Blue Cross and Blue Shield or your group may change the terms of Dental Blue Freedom. If this is the case, the change is described in a rider. Your plan sponsor can supply you with any riders that apply to your benefits.

Under Dental Blue Freedom, your coverage consists of two levels of benefits: in-network benefits; and out-of-network benefits. The highest level of benefits is provided when you obtain your covered dental services from a dentist who has been identified in your Dental Blue Freedom Benefit Description and riders as covered dentists for in-network benefits. When you receive covered dental services from other dentists, you will receive a lower level of benefits. Your cost will be more for these covered dental services. Your Dental Blue Freedom Benefit Description and the riders that are part of your Dental Blue Freedom Benefit Description identify those dentists who will be covered at the highest level of benefits, and they also show the amounts that you must pay for covered dental services when you use an in-network dentist or when you use an out-of-network dentist.

Before using your benefits, you should remember there are limitations or exclusions. Be sure to read the limitations and exclusions on your benefits that are described in Parts 2, 3, 4 and 5.

(In this Benefit Description, the term “you” refers to any member who has the right to the benefits provided under Dental Blue Freedom—the subscriber or the enrolled spouse or any other enrolled dependent.)