Blue Shield of California dental options for federal employees visit us at blueshieldca.com You can help protect your health by taking care of your teeth. Regular oral care is an important part of maintaining good overall health and helps ensure that minor conditions are diagnosed before they become serious and costly. We can help you maintain a good dental regimen. With our dental plans, you get quality benefits, dependable customer service, and access to an extensive network of dentists. Keeping it simple and easy Our dental plans include: • Access to an extensive dental PPO or dental HMO provider network in California* • Affordable rates • Choice of dentists • Orthodontic coverage Our dental plans are available to all federal employees in California whether or not they enroll in the Blue Shield HMO or Blue Cross Blue Shield PPO health plan. Go to blueshieldca.com/fap for dental provider listings in your area. Something to smile about! Dental rates for 2013 You and any eligible dependents can be covered by your dental plan. Dental PPO Dental HMO Monthly Quarterly Monthly Quarterly Individual (adult) $42.61 $127.83 $23.38 $70.14 Two-party $80.51 $241.53 $44.77 $134.31 Family $125.39 $376.17 $65.50 $196.50 * Dental providers in and out of California are available through a contracted dental plan administrator. See inside for details on how to enroll!
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Blue Shield of California dental options for federal employees€¦ · When you select the Blue Shield dental PPO, you can see any dentist whenever you need covered services. To access
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Blue Shield of California dental options for federal employees
visit us at blueshieldca.com
You can help protect your health by taking care of your teeth. Regular oral care is an important part of maintaining good overall health and helps ensure that minor conditions are diagnosed before they become serious and costly.
We can help you maintain a good dental regimen. With our dental plans, you get quality benefits, dependable customer service, and access to an extensive network of dentists.
Keeping it simple and easy
Our dental plans include:
• AccesstoanextensivedentalPPOordentalHMOprovidernetwork in California*
• Affordablerates
• Choiceofdentists
• Orthodonticcoverage
Our dental plans are available to all federal employees in California whether or not they enroll in the Blue Shield HMOorBlueCrossBlueShieldPPOhealthplan.Gotoblueshieldca.com/fap for dental provider listings in your area.
Something to smile about!
Dental rates for 2013 You and any eligible dependents can be covered by your dental plan.
Dental ppo Dental hmo
Monthly Quarterly Monthly Quarterly
Individual (adult) $42.61 $127.83 $23.38 $70.14
Two-party $80.51 $241.53 $44.77 $134.31
Family $125.39 $376.17 $65.50 $196.50
* Dental providers in and out of California are available through a contracted dental plan administrator.
See inside for details on how to enroll!
DentalPPOadvantages
WhenyouselecttheBlueShielddentalPPO,youcanseeany dentist whenever you need covered services. To access care at the lowest out-of-pocket expense under this plan, you shoulduseanetworkdentist.Advantagesinclude:
• Accesstomorethan21,000dentalcareproviders in California
• Nocostformostannualpreventiveanddiagnostic care when you use a network provider
• Enhancedbenefitsforpregnantmemberswhouse a network provider
• A$2,500permember,peryearbenefitmaximum,*including a $1000 per member, per year maximum for out-of-network benefits
• Anaffordabledeductibleof$50permember,percalendar year
• Nowaitingperiodsforannualpreventiveand diagnostic care
• Orthodonticcoverage
• Annualoralcancerscreening
* Eachcalendaryear,thememberisresponsibleforallchargesincurredafter the plan has paid this amount for covered dental services.
If your dental coverage is cancelled for any reason (voluntary cancel, nonpayment of premium, etc.), you will be eligible to re-enroll after 12 months from the date of cancellation.
Dental member services
If you have questions about dental services, providers, dentalplansandbenefits,pleasecallourMemberServicesrepresentatives at (888) 271-4929 and press “0.” They can help answer your questions. You can also go to blueshieldca.com/fap to find a provider near you.
Grievance and appeals process
We have established an appeals procedure for receiving, resolving,andtrackingmembers’complaints,grievances,and appeals with Blue Shield. For more information on this process,seetheGrievanceandAppealsProcesssectioninthe Evidence of Coverage and the plan contract.
choose your dental plans
Getthemostfromyour benefits – become a Blue Shield
dental option member.
dental plan highlights
This chart is only a summary. For a complete list of the benefits, exclusions, and limitations of either dental plan, please refer tothedentalPPOordentalHMOEvidence of Coverage(EOC)andplancontract.We’llautomaticallysendyou acopyoftheapplicableEOCwhenyourdentalenrollmentisapproved.
ToreceiveanEOCforyourdentalplanpriortoenrollment,pleasecallourMemberServicesrepresentativesat (888) 271-4929 andpress“0”.Theshaded“non-network”columnunderDentalPPOshowswhatBlueShieldpays(rather than what you pay) because charges vary for dental services outside the Blue Shield network of dentists.
Periodontalrootplaning/perquadrant(D4341) $0 100% of charge 0 $40
1 Calendar Year Deductible applies to covered services other than diagnostic and preventive services and enhanced dental benefits for pregnant women.
2 Use any network dentist to take advantage of contracted rates and pay lower out-of-pocket costs.
3 When you use dentists who are not in our network, the plan reimburses up to the amountlistedinthiscolumn,andyou’reresponsibleforallchargesinexcessofthatamount.
4 DentalPPOmembershavecertainwaitingperiodsfromtheirdateofenrollment.For minor restorative services and procedures such as fillings, endodontics, peri-odontics,andoralsurgery:3months.Formajorrestorativeservicesandproceduressuch as crowns, orthodontics, removable and fixed prosthetics: 12 months.
5 Allservicesmustbeperformed,prescribed,orauthorizedbyyourdentalprovider,chosen from a current Blue Shield Dental Option Directory at blueshieldca.com. If you need to see a specialist, you must get a referral from your dental provider to receive covered services.
6 Coverage for sealants is limited to the first and second permanent molars.
7 Plusthecostofpreciousorsemi-preciousmetals.
8 One additional routine adult prophylaxis (including periodontal prophylaxis for gingivitis) for women during pregnancy and one periodontal maintenance visit if warranted by a history of periodontal treatment and one course (up to four quad-rants) of periodontal scaling and root planing for women during pregnancy with a documented existing periodontal condition.
Calendar Year maximums:
$2500 per member when you use a participating dentist
$1000 per member when you use a nonparticipating dentist
Combined annual maximum not to exceed $2500.
Calendar Year Deductible1: $50 per member
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This pamphlet is only a summary of the benefits of the Blue Shield dental plan. Detailed information regarding this plan (including processing guidelines) is in the
Evidence of Coverage.ThebenefitsdescribedinthispamphletareneitherofferednorguaranteedunderthecontractwiththeFEHBP,butaremadeavailabletoall
Withover21,000dentalPPOand9,000dentalHMOprovidersinCalifornia,*BlueShield dental members will have access to a large network of dentists.
Gotoblueshieldca.com to find a dental provider in your area. Click Find a Provider, Find a Dentist, and choose Dental PPO or Dental HMO. For questions about dental services, providers, dental plans and benefits, please callMemberServicesat(888) 271-4929 and press “0” for assistance.
* Dental providers in and out of California are available through a contracted dental plan administrator.