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.

DentalHMOadvantages

WhenyouselecttheBlueShielddentalHMO,you’llhaveadentistthatcoordinatesallofyourfamily’sdentalcare.Plus,you’llenjoythefollowing:

• Accesstomorethan9,000dentistsinCalifornia

• Nodeductiblesandnocalendar-yearmaximums

• Nocopaymentforannualpreventiveanddiagnosticcarewhen you use a network provider

• Specialtycareavailablewithareferralfromyourdentist

• Nowaitingperiodsformostservices,includingdiagnosticand preventive services

• Orthodonticcoverage

• Virtuallynoclaimforms

Conditions of coverage

DentalPPOanddentalHMObenefitsareseparatefromthemedicalbenefitsofBlueShield’shealthplans.

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.

Dental ppo Dental hmo5

Services (Procedurecodesarelistednexttotheirrespectiveprocedures.)

You pay with network dentists:2

With non-network3 dentists, you are reimbursed up to:

Waiting period (in months)4

You pay with network dentists:

Diagnostic services

Comprehensive oral exams (D0150) $0 $40 0 $0

preventive care

Prophylaxis(cleanings,every6months)–adult(D1110) $0 $48 0 $0

Prophylaxis(cleanings,every6months)–child(D1120) $0 $34 0 $0

Sealant/per tooth6(coveredtoage16ondentalPPOandage21ondentalHMO)(D1351)

$0 $22 0 $0

Restorative services4

One-surface amalgam (filling) (D2140) $35 $28 3 $15

Crown (porcelain anterior and premolar teeth)7 (D2750) $320 $256 12 $2506

Endodontics4

Anteriorrootcanal(D3310) $156 $125 3 $125

Molarrootcanal(D3330) $234 $187 3 $225

periodontics4

Osseous surgery/per quadrant (D4260) $263 $210 3 $225

Periodontalrootplaning/perquadrant(D4341) $65 $52 3 $40

Removable prosthetics4

Complete denture (upper or lower) (D5110 or D5120) $388 $310 12 $250

oral surgery4

Extraction(singletooth)(D7140) $40 $32 3 $23

Removal of impacted tooth (complete bony) (D7240) $113 $90 3 $95

orthodontics4

Fully banded (two-year) case – child (D8080) $2,350 Notcovered 12 $1,800

Fully banded (two-year) case – adult (D8090) $2,650 Notcovered 12 $2,650

Enhanced dental benefits for pregnant women8

Prophylaxis(adult)(D1110) $0 100% of charge 0 $0

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

enrolleesanddependentswhoaremembersofthisplan.ThecostofthedentalplanisnotincludedintheFEHBPpremium;anycostforcovereddentalservicesdoes

notcounttowardanyFEHBPdeductible,out-of-pocketmaximumcopaymentcharges,etc.ThesebenefitsarenotsubjecttotheFEHBPdisputedclaimsprocedure.

dental networks at a glance

AMADOR

DELNORTE

TRINITYHUMBOLDT

PLUMAS

SIERRA

NEVADA

PLACER

TEHAMA

COLUSA

SUTTER

YUBA

SACRA-MENTO

YOLO

LAKE

BUTTEGLENN

MENDOCINO

SONOMA

MARIN

EL DORADO

ALPINENAPA

SOLANO

CONTRA-COSTA

SAN JOAQUIN

STANISLAUS

MERCED

FRESNO

MADERA

MARIPOSA

MONO

INYO

TULARE

KINGS

SAN BERNARDINO

KERN

LOS ANGELESVENTURA

SANTA BARBARA

SAN LUIS OBISPO

MONTEREY

SAN BENITO

ORANGE RIVERSIDE

SAN DIEGO

IMPERIAL

TUOLUMNE

ALAMEDASAN FRANCISCO

MENDOCINO

SAN MATEO

SANTA CRUZ

MODOCSISKIYOU

SHASTA LASSEN

AMADOR

CALAVER

AS

SANTACLARA

Dental HMO and PPO providers

Dental PPO providers only

Access to non-network dental providers only

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.