BluePreferred Dental Plans. for employers

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1 BluePreferred Dental Plans for employers

2 Why Provide a Dental Plan? If you re looking to improve the health of your employees, providing medical coverage may not be enough. Oral health can have a significant impact on an individual s quality of life. According to a 03 Towers Watson/National Business Group on Heath employer survey, providing affordable health care is key to a company s ability to provide a competitive reward package and to succeed long term in supporting their employee value proposition, and meeting attraction and retention goals. According to a recent survey by the American Payroll Association, 44% of respondents ranked health benefits above wages when considering a job. By providing dental coverage from Blue Cross Blue Shield of Arizona (BCBSAZ), you not only improve the general health and wellness of your staff, you also add an attractive facet to your benefit plan, which helps you attract talent. The end result a happier, more talented, and more productive team. Visit /DentalHealth to learn more about how dental health contributes to overall well-being. Survey on Purchasing Value in Health Care; Towers Watson/National Business Group on Health Employer ( Getting Paid in America; American Payroll Association (

3 What s New? An opportunity to choose how your plan will cover certain restorative services More control over non-network reimbursement levels No more waiting periods for Type III coverage in select plans No requirement for any dental group to purchase BCBSAZ medical coverage What s Still Great! 00% in-network coverage for diagnostic and preventive services in all standard plans Deductible is waived for diagnostic and preventive services even with non-network dentists BCBSAZ s dental network includes more than,00 general and specialty providers throughout Arizona with extended access to a separate national network with more than 00,000 dental office locations. Dental plan designs for employers with as few as two employees Orthodontic riders available with coverage options for children and adults And some plans include: Maximum Carryover Provision to allow unused benefits to be carried into future years Prevention + feature provides additional coverage for pregnant and diabetic members Diagnostic and preventive services do not count against the annual plan maximum Internal BCBSAZ data Data from DenteMax, dental network intermediary which is responsible for contracting with non-arizona dentists. DenteMax is an independent company that is not affilated with BCBSAZ. 3

4 Why BluePreferred Dental? One size does not fit all. Designed to offer maximum value while helping you manage costs and save time, BluePreferred Dental is changing the face of dental coverage. There is still a wide variety of standard plan designs to choose from, but there are now options where you can pick specific plan design elements to meet your specific cost or benefit objectives. For example, many of the standard plans offer an option to allow coverage for some restorative services to be classified as either a Type II service or as a Type III service, giving you added flexibility in choosing a benefit design. Flexible benefits for a wide range of services. Plan options include services ranging from regular exams, cleanings and fillings to full-featured options with coverage extending to crowns, bridges and dentures. Orthodontics coverage can also be added for groups that qualify. After an annual deductible, benefits are available at varying coinsurance levels for covered services. For larger employer groups, benefits can be highly customized to meet the needs of your growing business. Exclusions and Limitations: Plans do not cover all dental expenses and have exclusions and limitations. All plans generally exclude coverage for services and supplies that are experimental, investigational, cosmetic, or which BCBSAZ deems not dentally necessary. All plans impose member cost share requirements. Depending on the plan, cost share may include deductibles and coinsurance in percentages that vary based on plan type, deductible level, provider s network status, and benefit type. For voluntary plans, waiting periods may apply for some services and members. 4

5 Active plan designs & in-network utilization. Encouraging use of in-network providers is a key strategy in lowering out-of-pocket costs for members. BluePreferred Dental plans promote in-network utilization through active benefit designs with lower coinsurance for in-network providers while also offering members a large network to choose from. Out-of-network providers don t have a contract with BCBSAZ. This means they can set their own rates, collect up to full billed charges, and have no obligation to file members claims with BCBSAZ. By using an in-network provider, members can keep their costs low and make responsible dental care decisions that benefit you, their employer. In-Network Provider Out-of-Network Provider Billed charge $40 Billed charge $40 BCBSAZ in-network fee $00 BCBSAZ in-network fee $00 BCBSAZ pays (80% x $00) $ 80 BCBSAZ pays (60% x $00) $ 60 Member pays (0% x $00) $ 0 Member pays (40% x $00) $ 40 Difference of billed charge NA Plus difference of billed charge $ 40 Member s Out-of-Pocket Cost: $ 0 Member s Out-of-Pocket Cost: $ 80 While actual expenses will vary, in this example the member would have saved $60 by using an in-network provider and would have balance billing protection. The example on the left shows how use of an in-network provider may save money. This example assumes the following: The member has already met the annual deductible The member has 80% coinsurance for in-network providers The member has 60% coinsurance for out-of-network providers The dentist s billed charge is $40 BCBSAZ s established in-network fee is $00 Least expensive available treatment (LEAT) does not apply 5

6 BluePreferred Dental Plans BluePreferred plans fit any budget and have been designed to lower your employees out-of-pocket costs especially when network dentists are utilized. And if extensive treatment is needed by any plan member, his or her dentist can submit a predetermination request to BCBSAZ in advance of actual services to receive an estimate of the treatment based on the member-specific plan design and current benefit status. This encourages open communication between dentist and patient and avoids financial surprises for plan members. Standard plans include: 00% coverage for all covered Type I diagnostic/preventive services (in-network) Deductible is waived for all covered Type I diagnostic/preventive services Type I diagnostic/preventive services don t count toward the calendar year maximum in most plans which frees benefit dollars for more expensive restorative treatment In addition, most standard plans include a Maximum Carryover Provision and a Prevention + feature with extended coverage (please see details in the following pages) We re here to help you Ask about customized plans for large groups. Combined billing available take care of your health and dental insurance at once. (60) (800) 3-345, ext. 579 For plans A, A, and all voluntary plans, Type I services are subject to calendar year maximums. These value added features are included in all standard plan designs except for Plan A, A, and voluntary options. 6

7 Added Features: Maximum Carryover Provision Rewarding Good Oral Health Habits Regular dental visits are very important to maintaining good oral health. BluePreferred Dental members who regularly see their dentists are rewarded, in some circumstances, with the ability to carry over unused benefit dollars from one year to the next. Members can take advantage of this Maximum Carryover Provision when both of the following happen during the same calendar year.. BCBSAZ pays at least one claim. Total claims paid by BCBSAZ do not exceed $500 When both of these criteria are met, the member accumulates an additional carryover credit of up to $50, over and above the annual benefit maximum, to be available in future years. Members may continue to accumulate carryover dollars for every calendar year in which the member meets the carryover requirements, up to a maximum of $,000 total carryover dollars at a time. Prevention + Feature Connecting Oral Health to Good Overall Health Most BluePreferred Dental plans include a special feature to help diabetics and pregnant women obtain preventive services to deal with these higher risks. Specifically, all diabetic and pregnant members are eligible for coverage of one additional dental cleaning procedure or one periodontal maintenance procedure per year. These extended benefits will remain available to members for the duration of their conditions. Medical studies have long made a connection between good oral health and good overall health. For example, gum disease is often linked to serious complications for diabetics and pregnant women. In fact, the American Dental Association (ADA) specifically warns that women are more likely to develop gingivitis during pregnancy. Optional Orthodontics Riders for All Plans Options Family Members Covered: Child Only or Adult & Child Lifetime Maximum per Covered Member: $,000; $,500; $,000 All Orthodontic Riders 3 Not subject to meeting dental plan deductible Not subject to dental plan calendar year benefit maximum Child-only coverage is through age 8 In-network and out-of-network coinsurance: 50% Minimum number of enrolled employees: 0 Please read plan documents carefully to understand the terms and conditions for these features. These value added features are included in all standard plan designs except for Plan A, Plan A, and voluntary options. Effect of Intensive Oral Hygiene Regimen During Pregnancy on Periodontal Health, Cytokine Levels, and Pregnancy Outcomes: A Pilot Study. Journal of Periodontology, December 04, Vol. 85, No., Pages ( 3 Waiting period for orthodontia services will be waived if group has comparable comprehensive orthodontia coverage immediately prior to the group s transfer to BluePreferred Dental coverage. The waiting period will be waived only for employees and their dependents enrolled in such prior coverage at the time the group transfers to BluePreferred Dental. 7

8 Important Flexibility Features Alternative Out-of-Network Reimbursement for groups with 5 or more employees BCBSAZ can accommodate requests, from employers of size 5 or more, to increase reimbursement for services provided by out-of-network dentists in Arizona. For services delivered in the state, we typically use the same allowed amount to process claims for both in-network and out-of-network services. Alternative reimbursement increases the allowed amount for out-ofnetwork services by 0 percent, leaving employees responsible for a smaller difference between the allowed amount and the charges billed by an out-ofnetwork provider in Arizona. This alternative out-of-network reimbursement arrangement is a good solution for group clients with employees located in areas where access to in-network dentists may be limited. Flexibility to Manage Benefit Category Descriptions Most dental insurance plans cover treatment for endodontic, periodontal and oral surgical services in one of two different benefit categories - Type II (minor restorative) or Type III (major restorative). For employers of size 5 or more, BCBSAZ provides the opportunity in select plans to allow employers to make the choice that best fits their requirements or benefit dollar budget. Plan Comparison for Groups of 0 or More Plan A Plan A Plan 3A Plan 4A Benefit and Network Features Active Active Active Active In and Out of Network In Out In Out In Out In Out Type I Diagnostic and Preventive Services 3 00% 80% 00% 80% 00% 80% 00% 80% Type II Basic Restorative Services 3 80% 60% 50% 40% 80% 60% 80% 60% Type III Major Restorative Services 3 Not Covered 50% 40% 50% 40% 50% 40% Benefit Maximum per Member per Calendar Year $500 $500 $,000 $,500 Annual Individual Deductible $50 $50 $00 $00 Annual Family Deductible $50 $50 $00 $00 Deductible Waived for Diagnostic & Preventive Services Yes Yes Yes Yes Type I Services Count Toward Calendar Year Benefit Maximum Yes Yes No No Waiting Periods for Type III Services months N/A None None None Ability to move Type III endodontic, periodontal and oral surgical procedures into Type II benefit category. (For No No Yes Yes groups of 5 or more employees.) Ability to choose Alternate Out-of-Network reimbursement level. (For groups of 5 or more employees.) No No Yes Yes Coverage for Orthodontic Benefits Available Yes Yes Yes Yes Minimum Group Size These features can be used, by groups of 5 or more employees, to customize all plans except A, A, and voluntary plans. Because BCBSAZ determines payment for dental services based on the lesser of billed charges or the applicable allowed amount, reimbursement will never exceed the dentist s billed charges. 3 For services included in each category, please see the grid on page 0. Please see page5 for benefit limitations and exclusions. 8

9 Plan Comparison for Groups of 0 or More Plan 5A Plan 5P Plan 6A Plan 6P Benefit and Network Features Active Passive Active Passive In and Out of Network In Out In Out In Out In Out Type I Diagnostic and Preventive Services 00% 80% 00% 00% 80% 00% Type II Basic Restorative Services 80% 60% 80% 80% 60% 80% Type III Major Restorative Services 50% 40% 50% 50% 40% 50% Benefit Maximum per Member per Calendar Year $,000 $,000 $,500 $,500 Annual Individual Deductible $50 $50 $50 $50 Annual Family Deductible $50 $50 $50 $50 Deductible Waived for Diagnostic & Preventive Services Yes Yes Yes Yes Type I Services Count Toward Calendar Year Benefit Maximum No No No No Waiting Periods for Type III Services months None None None None Ability to move Type III endodontic, periodontal and oral surgical procedures into Type II benefit category. (For Yes Yes Yes Yes groups of 5 or more employees.) Ability to choose Alternate Out-of-Network reimbursement level. (For groups of 5 or more employees.) Yes Yes Yes Yes Coverage for Orthodontic Benefits Available Yes Yes Yes Yes Minimum Group Size Plan 7A Plan 7P Benefit and Network Features Active Passive In and Out of Network In Out In Out Type I Diagnostic and Preventive Services 00% 80% 00% Type II Basic Restorative Services 90% 70% 90% Type III Major Restorative Services 60% 40% 60% Benefit Maximum per Member per Calendar Year $,000 $,000 Annual Individual Deductible $5 $5 Annual Family Deductible $75 $75 Deductible Waived for Diagnostic & Preventive Services Yes Yes Type I Services Count Toward Calendar Year Benefit Maximum No No Waiting Periods for Type III Services months None None Ability to move Type III endodontic, periodontal and oral surgical procedures into Type II benefit category. (For Yes Yes groups of 5 or more employees.) Ability to choose Alternate Out-of-Network reimbursement level. (For groups of 5 or more employees.) Yes Yes Coverage for Orthodontic Benefits Available Yes Yes Minimum Group Size 0 0 For services included in each category, please see the grid on page 0. Please see page5 for benefit limitations and exclusions. 9

10 For Groups of Size 0 or More Type I Covered Services Diagnostic and Preventive (deductible waived for Type I services) Oral exams Two per year in any combination of periodic, limited, or comprehensive exams Prophylaxis Cleanings Two per year Type II periodontal maintenance procedures, if any, count toward this maximum of two cleanings Bitewing X-rays One set per year Periapical X-rays Up to four films per year Full Mouth X-rays One per five year period Topical Fluoride Through age 8 One per year Sealants Through age 5 permanent molars and bicuspids only, once per three year period Space Maintainers Through age 5 Type II Covered Services 3 Claims for certain Type II services are subject to processing based on the least expensive available treatment (LEAT). Amalgam Fillings One treatment per tooth in any two year period (limit based on amalgam and composite fillings combined) Composite Fillings Anterior (Front) Teeth One treatment per tooth in any two year period; not subject to LEAT processing (limit based on amalgam and composite fillings combined) Composite Fillings Posterior/Bicuspid (all except front) Teeth Simple Extractions Emergency Palliative Treatment Endodontics Pulpal Therapy Periodontics Non Surgical One treatment per tooth in any two year period (limit based on amalgam and composite fillings combined) Surgical extractions covered under Type III Covered for emergency treatment of dental pain One treatment per tooth in any two year period One per two year period Periodontal maintenance procedures are not included in this limit, but are counted toward the prophylaxis limit. Covered Oral Appliances for Treatment of Bruxism Type III Covered Services 3, 4 Claims for certain Type III services are subject to processing based on the least expensive available treatment (LEAT). Prosthodontics Bridges & Dentures Five year replacement limit Oral Surgery Extractions Limited Coverage (can be covered under Type II for groups of 5 or more) General Anesthesia Limited Coverage per BCBSAZ dental coverage guidelines 5 Endodontics Root Canal One treatment per tooth in any two year period (can be covered under Type II for groups of 5 or more) Crowns/Inlays/Onlays Periodontics Surgical Five year replacement limit One procedure per three year period (can be covered under Type II for groups of 5 or more) All per year benefits mean per calendar year. Any combination of x-rays billed on the same date of treatment cannot exceed the allowed amount for a full mouth x-ray benefit. 3 Only the allowed amount, as based on least expensive available treatment (LEAT), if applicable, (and not billed charges) counts to satisfy the deductible.only the BCBSAZ portion of the allowed amount counts toward the calendar year benefit maximum. Any services in excess of a benefit limit or provided after you reach the calendar year benefit maximum are not covered. Please note: There may be several methods for treating a specific dental condition. All claims for restorative services such as fillings and crowns are subject to analysis for the least expensive available treatment (LEAT). Benefits for certain restorative procedures will be limited only to the LEAT. For these procedures, BCBSAZ will only pay benefits up to the LEAT fee. Members may elect to receive a covered service that is more costly than the LEAT but the member will be responsible for cost-share based on the LEAT, and will also pay the difference between the fee for the LEAT and the more costly treatment ( LEAT remainder ). Any payment made for this LEAT remainder will not count toward deductible. 4 Type III services not covered for Plan A. 5 BCBSAZ Dental Coverage Guidelines are available upon request. Not all dentally necessary services are covered benefits. BCBSAZ offers a wide variety of standard benefit plans to groups of -99 employees. Larger groups may decide a standard plan meets their needs or choose to customize their benefits. 0

11 Voluntary Dental Benefit Options Group Voluntary Dental Options When an employer provides health coverage to employees through a BCBSAZ health plan but cannot afford to contribute to group dental coverage, BCBSAZ has a variety of voluntary solutions available. Our voluntary plans call for minimum participation of only 5% of total eligible employees and can be offered to groups with as few as two enrolled employees. No matter the group size, our benefit designs help keep employee costs as low as possible all without minimum employer contribution requirements. Full Featured Plan Designs with No Employer Contribution The voluntary plans available through BCBSAZ include comprehensive benefit designs with 00% in-network coverage for all covered diagnostic and preventive services. There are no deductible requirements for diagnostic and preventive services so members receive in-network covered services such as examinations, x-rays and teeth cleaning procedures with no out-of-pocket expenses. In addition to important preventive benefits, the voluntary plans also provide coverage for minor restorative treatment such as fillings and simple extractions without waiting periods. After months of enrollment, major services such as periodontal procedures (treatment of gums and surrounding tissues) endodontic procedures (root canal therapy) and prosthodontic services (crowns, dentures, bridges) are all available with annual plan maximum amounts of $,000 or $,500. Plan Designs and Network Availability to Help Control Costs The BCBSAZ voluntary plans include the BluePreferred Dental PPO network of dentists and using the network can help control dental costs. This is because BCBSAZ voluntary plans offer richer levels of coverage when employees use in-network dentists. Plus, network dentists will not charge a member more than the BCBSAZ allowed amount, so your employees are protected from balance billing. Helping to Bring Good Oral Health to Employees Even when an employer cannot afford to contribute toward group dental coverage, a voluntary dental program from BCBSAZ can help keep employees in good oral health through the focus on prevention and in-network savings. Four different benefit plans available No employer contribution requirements 00% benefits for in-network diagnostic and preventive treatment

12 Voluntary Plans Comparison Voluntary Plans for Groups of Size or More Plan 3V Plan 4V Plan 5V Plan 6V Benefit and Network Features Active Active Active Active In and Out of Network In Out In Out In Out In Out Type I Diagnostic and Preventive Services 00% 80% 00% 80% 00% 80% 00% 80% Type II Basic Restorative Services 80% 60% 80% 60% 80% 60% 80% 60% Type III Major Restorative Services 50% 40% 50% 40% 50% 40% 50% 40% Benefit Maximum per Member per Calendar Year $,000 $,500 $,000 $,500 Annual Individual Deductible $00 $00 $50 $50 Annual Family Deductible $00 $00 $50 $50 Deductible Waived for Diagnostic & Preventive Services Yes Yes Yes Yes Type I Services Count Toward Calendar Year Benefit Yes Yes Yes Yes Maximum Waiting Periods for Type III Services months Yes Yes Yes Yes Ability to move Type III endodontic, periodontal and oral surgical procedures into Type II benefit No No No No category. Ability to choose Alternate Out-of-Network reimbursement level No No No No Coverage for Orthodontic Benefits Available Yes Yes Yes Yes Minimum Group Size For services included in each category, please see the grid on page 3. Please see page5 for benefit limitations and exclusions. Available for groups with at least ten enrollees.

13 Voluntary Plans for Groups of Size or More Type I Covered Services Diagnostic and Preventive (deductible waived for Type I services) Oral exams Two per year in any combination of periodic, limited, or comprehensive exams Prophylaxis Cleanings Two per year Type III periodontal maintenance procedures, if any, count toward this maximum of two cleanings Bitewing X-rays One set per year Periapical X-rays Up to four films per year Full Mouth X-rays One per five year period Topical Fluoride Through age 8 One per year Sealants Through age 5 permanent molars and bicuspids only, once per three year period Space Maintainers Through age 5 Type II Covered Services 3 Claims for certain Type II services are subject to processing based on the least expensive available treatment (LEAT). Amalgam Fillings One treatment per tooth in any two year period (limit based on amalgam and composite fillings combined) Composite Fillings Anterior (Front) Teeth One treatment per tooth in any two year period; not subject to LEAT processing (limit based on amalgam and composite fillings combined) Composite Fillings Posterior/Bicuspid (all except front) Teeth Emergency Palliative Treatment Type III Covered Services 3, 4 One treatment per tooth in any two year period (limit based on amalgam and composite fillings combined) Covered for emergency treatment of dental pain Claims for certain Type III services are subject to processing based on the least expensive available treatment (LEAT). Prosthodontics Bridges & Dentures Five year replacement limit Oral Surgery Extractions Limited Coverage Simple Extractions Surgical extractions also covered under Type III General Anesthesia Limited Coverage per BCBSAZ dental coverage guidelines 5 Endodontics Root Canal One treatment per tooth in any two year period Endodontics Pulpal Therapy One treatment per tooth in any two year period Crowns/Inlays/Onlays Five year replacement limit Periodontics Non Surgical One procedure per two year period Periodontal maintenance procedures are not included in this limit, but are counted toward the prophylaxis limit. Periodontics Surgical One procedure per three year period All per year benefits mean per calendar year. Any combination of x-rays billed on the same date of treatment cannot exceed the allowed amount for a full mouth x-ray benefit. 3 Only the allowed amount, as based on least expensive available treatment (LEAT), if applicable, (and not billed charges) counts to satisfy the deductible. Only the BCBSAZ portion of the allowed amount counts toward the calendar year benefit maximum. Any services in excess of a benefit limit or provided after you reach the calendar year benefit maximum are not covered. Please note: There may be several methods for treating a specific dental condition. All claims for restorative services such as fillings and crowns are subject to analysis for the least expensive available treatment (LEAT). Benefits for certain restorative procedures will be limited only to the LEAT. For these procedures, BCBSAZ will only pay benefits up to the LEAT fee. Members may elect to receive a covered service that is more costly than the LEAT but the member will be responsible for cost-share based on the LEAT, and will also pay the difference between the fee for the LEAT and the more costly treatment ( LEAT remainder ). Any payment made for this LEAT remainder will not count toward deductible. 4 Waiting period for Type III services will be waived if group has comparable comprehensive dental coverage immediately prior to the group s transfer to BluePreferred Dental coverage. The waiting period will be waived only for employees and their dependents enrolled in such prior coverage at the time the group transfers to BluePreferred Dental. 5 BCBSAZ Dental Coverage Guidelines are available upon request. Not all dentally necessary services are covered benefits. 3

14 Why Choose Blue? Easy Access to Dental Care A statewide network of general and specialty dentists and arrangements with an independent, nationwide dental network mean it s easy for your employees to access dental services when they need to, wherever they are. Our plans are designed to make it as simple and convenient as possible, with standard plans offering preventive care at 00% coverage in-network, without being subject to deductibles. In fact, for most plans preventive care doesn t count toward the calendar year maximum. Finally, we don t require preauthorization for any dental services. Affordable Products Access to services means little if members can t afford the bills. BCBSAZ plans were developed with this in mind, offering a wide range of benefit options to meet varying budgets. Dual-option arrangements are available, making it more affordable for employers to offer dental coverage, and give their employees the chance to choose between a value plan or a buy up option. Unmatched Service You want to provide the highest quality benefits for your employees in the most efficient way possible, and so do we. Your dental service team will make it easy to get the information you need, when you need it, and we re continually looking for ways to make claims submissions and processing easier and faster. In the end, it s easy to see why customers, employers, and health care professionals rate BCBSAZ as a carrier that consistently provides great service. A Name You Know and Trust Blue Cross Blue Shield of Arizona (BCBSAZ) is the largest Arizona-based health insurance carrier, serving more than. million people. Giving back to the community is a hallmark of our company, and we re proud our heritage of service helps improve the lives of Arizonans. Based on surveys conducted for BCBSAZ by Thoroughbred Research, 04. Blue Cross Blue Shield Association, About Us. 4

15 Exclusions and General Limitations for All Plans Notwithstanding any other provision in a BluePreferred Dental plan, no benefits will be paid for expenses associated with the following: Alternative Dentistry Non-traditional or alternative dental therapies, interventions, services and procedures; naturopathic and homeopathic dentistry; diet therapies; nutritional or lifestyle therapies Appliances, procedures, devices and services necessary to alter vertical dimension and/or restore an occlusion Athletic Mouth Guards including but not limited to, any procedures and services necessary to fabricate or create such mouth guards Behavior management of any kind Benefit-specific exclusions and services in excess of limitations listed in this book under particular benefits Biologic materials to aid in tissue regeneration Bleaching of any kind; both internal and external bleaching Body Art, Piercing and Tattooing Services related to body piercing, cosmetic implants, body art, tattooing and any related complications Charges associated with the preparation, copying or production of health records Complications of Noncovered Services Complications and consequences, whether immediate or delayed, arising from any condition or service not covered under this plan CT scans (e.g., cone beam) Correction of congenital malformations except as required by state law for newborns, adopted children and children placed for adoption Cosmetic Services and Any Related Complications Surgery and any related complications, procedures, treatment, office visits, consultations and other services for cosmetic purposes Counseling Counseling and behavioral modification services Court-Ordered Services Court-ordered testing, treatment and therapy, unless such services are otherwise covered under this plan as determined by BCBSAZ Deep sedation and general anesthesia, except as stated in this plan Dental implants and any related services or treatment for complications Enamel microabrasion Expenses for services that exceed benefit limitations Experimental or investigational services Fees Fees for unspecified adjunctive procedures, by report Fees Fees other than for dentally appropriate, in-person, direct member services Free Services Services you receive at no charge or for which you have no legal obligation to pay Gold foil restorations Government Services Services provided at no charge to the member through a governmental program or facility Inpatient or outpatient facility services any facility charges associated with covered professional services provided in an inpatient or outpatient facility Laboratory and pathology services Laminate veneers Local, regional block, and trigeminal division block anesthesia Locally administered antibiotics Major restorative and prosthodontics services performed on other than a permanent tooth. (For Plan A, major restorative and prosthodontic services are not covered.) Maxillofacial prosthetics and any related services Medications Dispensed in a Dentist s Office prescription medications and over-thecounter medications, including pharmaceutical manufacturers samples, dispensed to the patient in a dentist s office by any mode of administration. This does not include eligible injectable medications administered in the dentist s office Non-Dentally Necessary Services services that are not dentally necessary as determined by BCBSAZ. BCBSAZ may not be able to determine dental necessity until after services are rendered Nitrous oxide; oral or intravenous conscious sedation; oral, intravenous or intramuscular analgesics or anxiolytics. Occlusal guards for the treatment of temporomandibular joint syndrome or sleep apnea including but not limited to, any procedures and services necessary to fabricate or create such mouth guards Office visit for observation, during which no services are provided Oral hygiene instruction, except when provided as an integral part of a routine covered oral examination. Orthodontic services and tooth extractions relating to those services, unless otherwise specifically covered under a contract rider and listed as a covered service on the member s schedule page Over-the-Counter Items Medications, devices, equipment and supplies that are lawfully obtainable without a prescription Personal Comfort Items Services intended primarily for assistance in daily living, socialization, personal comfort, convenience and other non-medical reasons Services and Supplies Not Provided by a Dentist except dental prophylaxis and root planing performed by a licensed dental hygienist under the supervision and direction of a dentist Services for Idiopathic Environmental Intolerance Services associated with environmental intolerance from unknown causes (idiopathic), multiple chemical sensitivity, the diagnosis or treatment of environmental illness (clinical ecology), such as chemical sensitivity or toxicity from exposure to atmospheric or environmental contaminants, pesticides or herbicides Services from a Family Member Services delivered by an eligible provider who is a member of your immediate family. Immediate family means your parents, siblings, children, stepparents, stepchildren, spouse, grandparents, grandchildren and anyone related to you by marriage to the same degree as any of the preceding individuals. When a provider is also the covered person, services rendered by that provider for himself or herself are also excluded from coverage. Services from ineligible providers Services Paid for By Other Organizations Services customarily paid for by an employer, such as worksite or ergonomic evaluations; the government; a school; biotechnical, pharmaceutical or dental device industry sources; or other individuals and organizations Services prior to effective date Services provided after the member s coverage termination date Services related to or associated with noncovered services Skin grafts Telephonic and electronic consultations, except for interactive telemedicine services from an in-network dentist using audio and visual equipment to treat dental trauma, burns or infection, as required by law Therapy or treatment of the temporomandibular joint, orthognathic surgery, or ridge augmentation Training and education Transportation Transport services and travel expenses Workers Compensation Illnesses or injuries covered by Workers Compensation, unless the member is exempt from such coverage or has made a statutory opt-out election These additional exclusions apply to Plan A: Crowns, inlays and onlays Deep sedation and general anesthesia Endodontic root canal services Oral Surgery Procedures including but not limited to surgical tooth extractions, removal of lesions, and removal or repair of soft or bony tissue Periodontal surgical services Prosthodontic Services including but not limited to original placement of bridges, partial dentures and complete dentures; replacement of dentures or bridgework; bridge or denture repair; and denture relining or rebasing This exclusion applies to voluntary plans: Any kind of mouth guard, including but not limited to athletic mouth guards THIS PROVIDES A GENERAL SUMMARY OF BENEFITS ONLY. A COMPLETE DESCRIPTION OF ALL BENEFITS, LIMITATIONS AND EXCLUSIONS IS FOUND IN AND GOVERNED BY EACH PLAN S BENEFIT BOOK, WHICH IS ALSO SUBJECT TO THE PROVISIONS OF THE EMPLOYER S GROUP MASTER CONTRACT WITH BCBSAZ. 5

16 45-4 P.O. Box 3466, Phoenix, AZ D48 0/

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