Optional Dental Coverage

With Blue Shield health plans, you get extensive, quality health care benefits, friendly customer service, and the peace of mind that comes from knowing you’re covered by a leader in the health care industry.

Now, we’d like to offer you something that should really bring a smile to your face — dental coverage. All applicants who qualify for a Blue Shield Copay or Deductible Plan may choose between the Blue Shield Dental PPO and the Blue Shield Dental HMO for quality dental coverage at affordable rates.

The Blue Shield Dental PPO
With the Blue Shield Dental PPO, you have the freedom to choose any dental provider, but your out-of- pocket costs for covered services are lowest when you receive care from Participating Dentists. The Dental PPO features:

• An extensive network of general care and specialty dentists
• An individual deductible of $50 per member per calendar year
• A wide range of dental benefits, including diagnostic and preventive services at no out-of-pocket cost (see Benefit Highlights chart)
• Coverage even when you use an out-of-network dentist — the Plan reimburses you for up to a specified amount and you pay the balance of the total billed charges (see Benefit Highlights chart)
• A $1,000 per member per year benefit maximum — including a $500 per member per year maximum for out-of-network benefits (Each calendar year, the member is responsible for all charges incurred after the Plan has paid these amounts for covered dental services.)
• No waiting period for diagnostic or preventive services (see the Dental PPO Highlights chart, footnote 3, for specified waiting periods)

The Blue Shield Dental HMO
With the Blue Shield Dental HMO, you choose a dental care location from our list of Blue Shield Dental HMO Dental Centers. All of your family’s dental care will be provided or coordinated through that Dental Center. The Dental HMO features:

• No deductibles or calendar year maximums
• A wide range of dental benefits, including most diagnostic and preventive services at no out-of-pocket cost to you, and generally lower copayments than the Dental PPO (see Benefit Highlights chart)
• Specialty care available with a referral from your Dental Center
• No waiting period for any type of service other than orthodontics (a 12-month waiting period applies to orthodontic services)
• No claim forms

In-network benefits of both the Blue Shield Dental PPO and the Blue Shield Dental HMO will be underwritten and administered by “the Dental Plan Administrator,” Dental Benefit Providers of California, Inc. Dental PPO out-of-network benefits will be underwritten by Blue Shield and administered by the Dental Plan Administrator.

Conditions of Coverage
Dental PPO and Dental HMO plan benefits are separate from the medical benefits of the Blue Shield Copay and Deductible Plans. Except for the following, however, the general provisions and exclusions of the Plans apply:

• Dental PPO and Dental HMO benefits are not subject to the health plan deductible requirements, and do not accumulate toward the maximum calendar year copayment responsibility.
• If your dental coverage is canceled for any reason (by you or by Blue Shield), you may apply for reinstatement, but your coverage (if approved) will be subject to a waiting period of 12 months from the cancellation date.

It’s Easy to Enroll!
If your application for a Blue Shield individual or family health plan is approved, you qualify for the Blue Shield Dental PPO or Dental HMO. All you need to do is mark your selection on the health plan appli-cation. If your health plan application is approved, your dental coverage will take effect on the same day as your health plan.* You and any dependents covered on your Blue Shield health plan will be covered by the dental plan you choose.

If you are signing up for the Blue Shield Dental HMO please be sure to list a Dental Center for yourself and your family on your application. If you do not have a copy of Blue Shield’s Dental HMO Dental Center Directory, contact Dental Member Services at 1-888-679-8928.

Monthly Dental Coverage Rates