Dental Blue RET - Dental Benefits

Dental Benefits

 

Your Benefits Payable Riders that are part of your Dental Blue Freedom Benefit Description describe all the amounts that you must pay for covered dental services. These Benefits Payable Riders include an explanation of your deductible, calendar-year benefit maximum and coinsurance. Your Dental Blue Freedom benefits will be provided based on the Benefits Payable Riders that are in effect for your Dental Blue Freedom benefits at the time your covered dental services are furnished.

Your Deductible
Some or all of your Dental Blue Freedom benefits may be subject to a deductible. Your “Deductible” Benefits Payable Rider shows the amount of your deductible and your “Benefit Level” Benefits Payable Rider shows those covered dental services for which the deductible applies. (Your deductible, if any, applies to the benefits you receive under the Dental Blue PPO plan and the Dental Blue plan combined.)
Your Calendar-Year Benefit Maximum
All of your Dental Blue Freedom benefits are subject to a calendar-year benefit maximum for each member. Your “Overall Benefit Maximum” Benefits Payable Rider shows the amount of your benefit maximum. This benefit maximum includes those benefits you receive under the Dental Blue PPO plan and the Dental Blue plan combined. (Note: Any dollar amount applied toward a calendar-year maximum under prior Dental Blue PPO or Dental Blue plans will be applied to your calendar-year maximum under Dental Blue Freedom.)

(this maximum does not apply for orthodontic benefits; refer below to “Orthodontic Coverage”)

Your Benefit Levels
The Benefits Payable Riders that are part of your Dental Blue Freedom Benefit Description describe the amounts that you must pay for covered dental services. In addition to the deductible and overall benefit maximum, the Benefits Payable Riders describe the coinsurance amounts that you must pay for Group 1 Services, Group 2 Services and Group 3 Services.
Orthodontic Coverage
If you have orthodontic coverage as part of Dental Blue Freedom, your Orthodontic Endorsement shows the amount of your lifetime benefit maximum and any age restrictions that may apply to these benefits. If you have these benefits, any maximum and age restrictions apply to benefits you receive under the Dental Blue PPO plan and the Dental Blue plan combined.

(these services are not covered under Dental Blue Freedom unless your group has purchased orthodontic coverage)

Enhanced Dental Benefits

For certain dental care services furnished on and after July 1, 2007, Dental Blue Freedom includes Enhanced Dental Benefits. Enhanced Dental Benefits will be provided for the following dental care services when the member is eligible for and has qualified to receive these Enhanced Dental Benefits.

  • Dental cleanings (oral prophylaxis or periodontal maintenance cleanings) once every three months. (There must be at least three months between any cleanings covered under Dental Blue Freedom, including these Enhanced Dental Benefits.)
  • A periodontal scaling once for each quadrant every 24 months when this service is necessary and appropriate.

Important Note: For these Enhanced Dental Benefits, any deductible, coinsurance (for in-network benefits only) and calendar-year benefit maximum provisions that would otherwise apply for your dental benefits do not apply. (The coinsurance that applies for out-of-network benefits for Enhanced Dental Benefits will not be more than 20%. In some cases, this coinsurance may be less than 20%. This will happen if the coinsurance amount specified in your Benefits Payable Rider is less than 20%.)

Who Is Eligible for Enhanced Dental Benefits
You are eligible to receive these Enhanced Dental Benefits when one of the following situations applies:

  • You are a member who has been diagnosed with diabetes; or
  • You are a member who has been diagnosed with coronary artery disease; or
  • You are a member who is pregnant.

Enhanced Dental Benefits will be available for the entire duration of the medical condition that makes you eligible for these benefits, as long as you continue to be enrolled in a Dental Blue Freedom option that includes these Enhanced Dental Benefits. From time to time, Blue Cross and Blue Shield may ask you to submit documentation from your physician that your medical condition still qualifies you to receive coverage for these additional dental services.

How to Qualify for Enhanced Dental Benefits
You will automatically qualify for these Enhanced Dental Benefits when you take part in a Blue Cross and Blue Shield disease management program for members with diabetes or coronary artery disease, or you take part in the Blue Cross and Blue Shield outreach program for expectant mothers.

To qualify for these Enhanced Dental Benefits when you do not take part in one of these programs, you must submit an Enhanced Dental Benefit Enrollment Form to Blue Cross and Blue Shield for authorization. To obtain this enrollment form, you may call the Blue Cross and Blue Shield customer service office at the toll-free telephone number shown on your Dental Blue Freedom identification card. You must have your physician complete and sign this enrollment form. Once completed, return the form to the address shown on the form. Within 30 calendar days of receiving your enrollment form, Blue Cross and Blue Shield will send you a letter approving you for these Enhanced Dental Benefits, provided you meet one of the conditions to be eligible for this additional coverage. If your request is denied, the letter you receive from Blue Cross and Blue Shield will tell you how to request an appeal.

To find out more about Enhanced Dental Benefits, you may call the Blue Cross and Blue Shield customer service office at the toll-free telephone number shown on your Dental Blue Freedom identification card.