2023 Blue Cross and Blue Shield Service Benefit Plan - Standard and Basic Option
Section 5(g). Dental Benefits
Page 121
Section 5(g). Dental Benefits
Page 121
Section 5(g). Dental Benefits
Important things you should keep in mind about these benefits:
- Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.
- If you are enrolled in a Federal Employees Dental/Vision Insurance Program (FEDVIP) Dental Plan, your FEHB Plan will be the primary payor for any covered services and your FEDVIP Plan will be secondary to your FEHB Plan. See Section 9, Coordinating Benefits with Medicare and Other Coverage, for additional information.
- Be sure to read Section 4, Your Costs for Covered Services, for valuable information about how cost-sharing works. Also, read Section 9 for information about how we pay if you have other coverage, or if you are age 65 or over.
- Note: We cover inpatient and outpatient hospital care, as well as anesthesia administered at the facility, to treat children up to age 22 with severe dental caries. We cover these services for other types of dental procedures only when a non-dental physical impairment exists that makes hospitalization necessary to safeguard the health of the patient (even if the dental procedure itself is not covered). See Section 5(c) for inpatient and outpatient hospital benefits.
- Under Standard Option,
- The calendar year deductible of $350 per person ($700 per Self Plus One or Self and Family enrollment) applies only to the accidental injury benefit below.
- The calendar year deductible of $350 per person ($700 per Self Plus One or Self and Family enrollment) applies only to the accidental injury benefit below.
- Under Basic Option,
- There is no calendar year deductible.
- You must use Preferred providers in order to receive benefits, except in cases of dental care resulting from an accidental injury as described below.
- There is no calendar year deductible.
Benefit Description
Accidental Injury Benefit
We provide benefits for services, supplies, or appliances for dental care necessary to promptly repair injury to sound natural teeth required as a result of, and directly related to, an accidental injury. To determine benefit coverage, we may require documentation of the condition of your teeth before the accidental injury, documentation of the injury from your provider(s), and a treatment plan for your dental care. We may request updated treatment plans as your treatment progresses.
Note: An accidental injury is an injury caused by an external force or element such as a blow or fall and that requires immediate attention. Injuries to the teeth while eating are not considered accidental injuries.
Standard Option - You Pay
Preferred: 15% of the Plan allowance (deductible applies)
Participating: 35% of the Plan allowance (deductible applies)
Non-participating: 35% of the Plan allowance (deductible applies), plus any difference between our allowance and the billed amount
Note: Under Standard Option, we first provide benefits as shown in the Schedule of Dental Allowances on the following pages. We then pay benefits as shown here for any balances.
Basic Option - You Pay
$30 copayment for associated oral evaluations
30% of the Plan allowance for all other care
Note: We provide benefits for accidental dental injury care in cases of medical emergency when performed by Preferred or non-preferred providers. See Section 5(d) for the criteria we use to determine if emergency care is required. You are responsible for the applicable cost-share amounts as shown above. If you use a non-preferred provider, you may also be responsible for any difference between our allowance and the billed amount.
Note: All follow-up care must be performed and billed for by Preferred providers to be eligible for benefits.
Accidental Injury Benefit
We provide benefits for services, supplies, or appliances for dental care necessary to promptly repair injury to sound natural teeth required as a result of, and directly related to, an accidental injury. To determine benefit coverage, we may require documentation of the condition of your teeth before the accidental injury, documentation of the injury from your provider(s), and a treatment plan for your dental care. We may request updated treatment plans as your treatment progresses.
Note: An accidental injury is an injury caused by an external force or element such as a blow or fall and that requires immediate attention. Injuries to the teeth while eating are not considered accidental injuries.
Standard Option - You Pay
Preferred: 15% of the Plan allowance (deductible applies)
Participating: 35% of the Plan allowance (deductible applies)
Non-participating: 35% of the Plan allowance (deductible applies), plus any difference between our allowance and the billed amount
Note: Under Standard Option, we first provide benefits as shown in the Schedule of Dental Allowances on the following pages. We then pay benefits as shown here for any balances.
Basic Option - You Pay
$30 copayment for associated oral evaluations
30% of the Plan allowance for all other care
Note: We provide benefits for accidental dental injury care in cases of medical emergency when performed by Preferred or non-preferred providers. See Section 5(d) for the criteria we use to determine if emergency care is required. You are responsible for the applicable cost-share amounts as shown above. If you use a non-preferred provider, you may also be responsible for any difference between our allowance and the billed amount.
Note: All follow-up care must be performed and billed for by Preferred providers to be eligible for benefits.
Accidental Injury Benefit - continued on next page