Outline Of Coverage - Blue Cross Blue Shield Of Massachusetts

Outline of CoverageThis document is a detailed description and summaryof benefits for Dental Blue 65 Preventive, Dental Blue 65Basic, and Dental Blue 65 Premier.Effective January 1, 2021EligibilityRequirements Age 65 or older Resident of MassachusettsPolicy Number: DENT SR (1–1–2012)“Read your subscriber certificate carefully.This disclosure statement is a very briefsummary of your dental plan. The planitself sets forth the rights and obligationsof both you and the insurance company.It is, therefore, important that you readyour subscriber certificate carefully.”Blue Cross Blue Shield of Massachusetts is an Independent Licenseeof the Blue Cross and Blue Shield Association.

We know that good oral health is importantto you, and we understand that dental costscan add up. From diabetes to heart diseaseand cholesterol levels, dental care may impactyour total health and well-being. Regular dentalcheckups help protect your smile, make you lookand feel better, and prevent problems down theroad.Outlined in this document is a detailed descriptionand summary of benefits for Dental Blue 65Preventive, Dental Blue 65 Basic, and DentalBlue 65 Premier, offered by Blue Cross BlueShield of Massachusetts.We offer paperless billing for your dentalpremiums through eBill.This easy-to-use tool allows you to view your statement and makepremium payments online. You also have an auto-draft option, wherewe set up an automatic withdrawal of premiums directly from yourbank account on each due date. Once you receive an initial paperinvoice, register for eBill at bcbsmaebilling.com.

OVERVIEWYour DentistIf You Have to File a ClaimDental Blue 65 offers access to morethan 90 percent of practicing dentistsin Massachusetts and more than 350,000provider locations nationwide. Out-of-areadentists who participate in our NationwideNetwork of dentists are also available toDental Blue members.Network dentists will send claims toBlue Cross Blue Shield of Massachusettsfor you. Just show them your Dental Blue 65ID card. The payment will be sent directly toyour dentist.If you already have a dentist and want toknow if he or she participates with BlueCross Blue Shield of Massachusetts, youmay call the dentist, refer to the most currentdental provider directory, or call MemberService at the toll-free number on your DentalBlue 65 ID card.If you receive care from a non-networkdentist, you may have to submit the claimyourself. If you file, send the AttendingDentist’s Statement form with the originalitemized bills. Any benefit payment willbe sent to you. You can get a copy ofthe Attending Dentist’s Statement fromMember Service.Coverage BeginsAny claims that you file should be sent toBlue Cross Blue Shield of Massachusetts,P.O. Box 986030, Boston, MA 02298.All member-submitted claims must bereceived within two years of the date ofservice. (Coverage is not available fornon-network dentists in Massachusettsexcept for covered emergency services.)Your coverage will be effective the first ofthe month following the month we receiveyour application.The Blue Cross Blue Shield GrievanceProgram is fully described in the subscribercertificate.New for 2021: EnhancedDental BenefitsOther InformationIf you would like help choosing a dentist,you may call the Physician Selection Serviceat 1-800-821-1388. You may also accessthe online dental provider directory atbluecrossma.org.Coordination of benefits (COB) applies toplan members who are covered by anotherplan for health care expenses. COB ensuresthat payments from all health care plansdo not exceed the total charges billed forcovered services.Effective January 1, 2021, Dental Blue 65plans now include Enhanced Dental Benefitsfor at-risk members with qualifying medicalconditions. Eligible members receiveadditional, condition-specific supportincluding full coverage for preventiveand periodontal services* that have beenconnected to improved overall health.Your subscriber certificate has a subrogationclause. This does not affect the scope ofbenefits. This clause allows claim paymentsto be retracted when a member recoverspayment for the same charges from a thirdparty due to liability for injury.*Available on plans that offer periodontal benefits;standard waiting periods apply.3

DENTAL BLUE 65 PREVENTIVEMonthly PremiumJanuary 1, 2021–December 31, 2021: 22.70Services & BenefitsYour covered services include: One complete initial oral exam, including initialdental history and charting of the teeth andsupporting structures Full mouth X-rays, 7 or more films, or panoramicX-ray with bitewing X-rays once every 60 months Bitewing X-rays once every 6 months Single-tooth X-rays as needed Study models and casts used in planning treatmentonce every 60 months Periodic or routine oral exams 3 times per 12 months Emergency exams Routine cleaning, scaling, and polishing of the teeth3 times per 12 monthsCo-insurance, Annual Deductible,and Annual MaximumThis dental plan provides full benefits basedon the allowed charge for participatingproviders. There are no annual deductiblesand no annual plan maximums.Waiting Periods and Pre-existingCondition LimitationsYour dental services will be covered fromyour effective date of this dental plan withouta waiting period or pre-existing conditionrestrictions.Exclusions and LimitationsServices limited by frequency includebut are not limited to: X-rays Exams CleaningsPlease review your dental policy for a fulllisting of limitations and exclusions.4

DENTAL BLUE 65 BASICMonthly PremiumOther Covered Services Occlusal adjustment, once each 24 months Services to treat root sensitivity General anesthesia when administered in conjunctionwith covered surgical services Emergency dental treatment to relieve acute pain Emergency dental treatment to control a dentalcondition that requires immediate care to preventpermanent harm to the memberJanuary 1, 2021–December 31, 2021: 37.80Services & BenefitsYour covered services include: 100% coverage for all services covered under DentalBlue 65 Preventive, plus 50% coverage for:Restorative Services Amalgam (silver) fillings (limited to one filling for eachtooth surface in each 12 months) Composite resin (tooth color) fillings on teeth (limitedto one filling per tooth surface in each 12 months) Pin retention for fillingsCo-insurance, Annual Deductible,and Annual MaximumThis dental plan provides: 100% coverage for all preventive services 50% coverage for services outlined in the plan’sServices & Benefits section above Coverage is based on the allowed charge forparticipating providers. There is a 100 annual deductible and 1,250calendar-year maximum.Oral Surgery Tooth extractions, root removal, and biopsiesPeriodontics (Gum and Bone) Periodontal scaling and root planning, once in eachquadrant each 24 months Periodontal surgery (soft-and hard-tissue surgeries),once in each quadrant each 36 months Periodontal maintenance following active periodontaltherapy, once each 3 monthsWaiting Periods and Pre-existingCondition LimitationsYour dental services will be covered fromyour effective date of this dental plan withouta waiting period or pre-existing conditionrestrictions for all preventive services. Forservices that fall outside of preventive, a sixmonth waiting period from the effective dateis required. If you’ve had continuous priordental coverage, you may be eligible to have allwaiting periods waived to allow you to receiveminor and major restorative services right away.Endodontics (Root and Pulp) Root canal therapy on permanent teeth, once perlifetime for each tooth Retreatment root canal therapy on permanent teeth,once in a lifetime for each tooth Other endodontic surgery intended to treat or removethe dental rootProsthetic Maintenance Repair of partial or complete dentures, crowns,and bridges, once each 12 months Adding teeth to existing partial or complete dentures Rebase or reline dentures, once each 36 months Recementing of crowns, inlays, onlays, and fixedbridgework, once each 12 monthsExclusions and LimitationsCertain services may be limited or excludedfrom this plan. These services may include: Fillings on tooth surfaces where a sealant was appliedwithin the prior 12 months Replacement of a filling within 12 months of the dateof prior restoration A service, supply, procedure, or appliance to stabilizeteeth when it is due to periodontal diseasePlease review your dental policy for a full listing oflimitations and exclusions.5

DENTAL BLUE 65 PREMIERMonthly PremiumJanuary 1, 2021–December 31, 2021: 68.70Service & BenefitsYour covered services include: 100% coverage for all services covered under DentalBlue 65 Preventive, plus 80% coverage for all services covered under DentalBlue 65 Basic, plus 50% coverage for: Prosthodontics (Tooth Replacement) Complete or partial dentures, including services tofabricate, measure, fit, and adjust them once each 60months for each arch Fixed bridges, including services to fabricate, measure,fit, and adjust them once each 60 months per tooth Replacement of dentures and bridges, but only whenthey are installed at least 60 months after the initialplacement, and only if the existing appliance cannotbe made serviceable Adding teeth to an existing bridge Temporary partial dentures to replace any of the sixupper or lower front teeth, but only if they are installedimmediately following the loss of teeth and during theperiod of healingMajor Restorative Services (Crowns, Inlays, Onlays) Crowns once each 60 months for each tooth Metallic, porcelain, and composite resin inlaysand onlays once every 60 months per tooth Surgical placement of dental implant onceper tooth per lifetime Replacement of crowns once every 60 monthsfor each tooth Replacement of metallic, porcelain, and compositeresin inlays and onlays once every 60 months Post and core or crown build up once every60 months per tooth 80% coverage for minor restorative services,oral surgery, periodontics, endodontics, prostheticmaintenance, and other services originally coveredby Dental Blue 65 Basic 50% coverage for major restorative services,prosthodontics/tooth replacements, crowns, inlays,onlays, dental implants and other services outlined inthe plan’s Services & Benefits section above Benefits are based on the allowed charge forparticipating providers There is a 50 annual deductible and 1,500calendar-year maximumWaiting Periods and Pre-existingCondition LimitationsYour dental services will be covered fromyour effective date of this dental plan withouta waiting period or pre-existing conditionrestrictions for all preventive services.For services that fall outside of preventive, a6-month waiting period from the effective dateis required for minor restorative services, anda 12-month waiting period from the effectivedate is required for major restorative services.If you’ve had continuous prior dental coverage,you may be eligible to have all waiting periodswaived to allow you to receive minor and majorrestorative services right away.Exclusions and LimitationsCertain services may be limited or excludedfrom this plan. These services may include: Fillings on tooth surfaces where a sealant was appliedwithin the prior 12 months Replacement of a filling within 12 months of the dateof prior restoration Duplicate dentures or bridgesCo-insurance, Annual Deductible,and Annual MaximumCast restorations, copings, or attachmentsfor installing overdentures, includingassociated endodontic procedures suchas root canals, precision attachments, orsemiprecision attachmentsThis dental plan provides: 100% coverage for all preventive servicesPlease review your dental policy for a full listing oflimitations and exclusions.6