Your card. Your dental health. - Premera Blue Cross

Your card. Your dental health.

Welcome!It’s no secret—good dental health affects your overall health.As your dental plan, we are here to provide you with the benefits and widerange of services to help you maintain and improve your dental—andeveryday—health. And we get you the best value when you need care.This guide highlights the many ways you can use your Premera Blue Cross BlueShield of Alaska DentalBlue plan to your advantage—whether it’s finding thedentist you want, getting the preventive care you need, or receiving the serviceyou expect.It all starts with your Premera member card—always carry your card with youand present it to your dentist when you seek care.premera.comTake control of your dental benefits and health withjust a few clicks. See page 7 for more information.2

Know how your dental plan works.Save yourself time and money. Your benefits are easy to find. Take a fewminutes to register and log in at premera.com. What you learn about yourplan could mean big savings.A dental plan in actionHere’s an example of how youmight share costs with yourdental plan when you visit anin-network dentist. Thisexample is based on a dentalplan where the member:• Is covered-in-full for preventive and diagnostic services, suchas routine exams, cleanings and x-rays. You pay no deductiblefor these services.• Pays a $50 deductible for basic and major dental servicesbefore the plan benefits take effect.• Pays 20 percent for basic dental services, such as fillings andsimple extractions. Your plan pays the remaining 80 percent.• Pays 50 percent for major dental services, such as crowns,dentures, bridges and implants. Your plan pays the remaining50 percent.SERVICE Cost Your share Plan’s shareRoutine exam $50 $0 $50Bitewing x-rays (4) $50 $0 $50Routine cleaning $100 $0 $100Simple extraction $175 Deductible $50 / $25 $100Anterior root canal $750 Deductible met / $150 $600Total $1,125 $225 $900Having a dental plan saved you $900!**This is only an example. Actual coverage varies by plan.Need a new card, or other help?Register and log in at premera.com when you need to order anew card or call Customer Service at 800-508-4722, Monday–Friday,between 8 a.m.–5 p.m., for assistance.3

Learnthe lingo.ter•mi•nol•o•gynoun: technical or specialterms used in a business.Here are some definitions to helpyou understand your dental plan:Annual maximum: The maximum amount Premerawill pay for all your benefits in one plan yearAllowable amount: The maximum amount Premerawill pay for a covered serviceBenefit: The portion of services your dental plan paysCopayment: A flat fee you pay at the time aservice is rendered. Copays don’t apply towardyour deductible.Deductible: The amount of money you pay everyyear before the plan pays for certain servicesCovered services: Dental care services and suppliesfor which your plan provides benefitsCovered-in-full: Dental care services that do notrequire a copayment or deductible. Your dental planpays the full amount owed to the provider.Coinsurance: Your share of the cost for a service.If your plan’s coinsurance share for a covered dentalservice is 80 percent, then you pay 20 percent of theallowable amount…after you meet your deductible.4Make the connection.Research shows that good oral health habits and regular preventivedental care help prevent periodontal disease. And they can reducethe risk of other health conditions such as diabetes and cardiovasculardisease. Make it a habit to visit your dentist regularly.

Access our dental providernetwork and get the best valuefrom your plan.Whether in Alaska or the lower 48, you get access to a broad network of contracted dentists.Alaska dentists want to be a part of our network because our dental plan offers comprehensivebenefits that our members can use, and we’re easy to work with.One advantage of using an in-network dentist is that you do not have to file a claim becausethey will file your claim for you. You save money when seeing a dentist that is part of ournetwork because we have made an agreement about the fees for their services on your behalf.You also get access to a nationwide network of contracted dentists, so you can find a dentistwhen you’re away from home.How do I find an in-network dentist?Go to premera.com/dentalhealth, and click on“Find a Dentist” in the “Member Tools” area.How do I find an in-network dentistin another state?You can go to premera.com/dentalhealth, clickon “Find a Dentist” in the “Member Tools”area, and choose the city and state where youneed to find an in-network dentist. Or callCustomer Service at 800-508-4722 for help.What happens when I use anout-of-network dentist?Out-of-network dentists have not made anagreement with us about fees for dentalservices. You may be subject to higher costsand the added paperwork of filing a claim.To learn more about filing a claim with anout-of-network provider, see page 10.5

Healthy teeth. Healthy you.Take advantage of your preventive dental care benefitsMost Premera dental plans cover routine preventive dental care in full when you see anin-network provider. So take advantage of these dental benefits to help prevent periodontal(i.e., gum) disease, especially when these dental services cost you little or nothing at all.Our preventive dental carebenefits include:• Routine oral exams, twice a year• Cleanings, twice a year• Sealants, for members under age 19 forpermanent teeth• Fluoride treatments, twice a year formembers under age 20• Bitewing x-rays, may be subject to frequencyThree things to remember• Know your benefits—check your benefitsonline to find out what is covered• Be informed—learn about dental care, andhow dental health affects your general health• See your dentist—get your teeth cleaned andexamined twice a year…you’re covered!About baby’s first dental examThe best age for a first dental exam is at oneyear old.* Pediatric dentists have the specialskills and training to work with very youngchildren, but many general dentists are veryadept with children as well. The followingdescribes a baby’s first dental exam:• The child’s teeth, jaw and oral tissues are examined• Parents will learn how to best position the child andcleanse their teeth• The dentist looks for potential problems and willcheck the child’s oral development• The child’s medical history will be reviewed, and anypreventive measures for dental disease discussed• The need for fluoride will be evaluated* Copyright 2002–2010 AmericanAcademy of Pediatric Dentistry6

Free online member tools.Inform and support your dental care decisionsVisit premera.com/dentalhealth. Here you’ll access online resources and information to help youget the most from your dental care for good dental health.Online dental tools include:• Find a dentist—anywhere in the U.S.• Dental health topics—peruse over 250 articlescovering care, diet, procedures, treatments,medications, disease, and dental problems• Dental benefit basics—learn the ins and outsof dental plans and benefits• Member tools—submit an online question to adentist or complete an online assessment to seeif you’re at risk for tooth decay, gum disease ororal cancerYour personalized member websiteat premera.comRegister and log in to find all your benefitsand claims information, up-to-date and in oneconvenient place. You’ll also find a variety ofgeneral health tools and resources at yourfingertips, including:• Personal Health Assessments• Personal Symptom Evaluator• Medical Library• “Health Helper” quizzes, trackers, calculatorsand an interactive program• Prescription drug tools and informationPremera.comFor tools you can use to help you get the most from your dental plan,care and health. Register and log in at premera.com.7

Meet the Explanation of Benefits(EOB) StatementUnderstand your claims and billing1 2 3 4 5 6 7 8 9 10 11An Independent Licensee of the Blue Cross Blue Shield AssociationThe EOB breaks down the charges submitted to Premera by your dentist, andit shows what benefits we pay for, how much we pay, and how much you areresponsible for.8

When you use an in-network dentist, he or she sends the dental claim directlyto us for payment. You may be responsible to pay a portion of the dental claimdepending on the amount paid by your dental plan.Definition of EOB Terms12345Service/product description—typeof service/product you received fromyour provider.Dates you received service/product—when you saw your provider (month/day/yearto month/day/year).Charges billed by provider —amount billedto you and your dental plan(s).Provider’s fee adjustment—differencebetween “charges billed by provider” and theamount network providers have agreed toaccept as full payment; see “Message Codes”at the bottom of your EOB for details.Your copay, deductible or amount notcovered—“copay” is a set fee you pay aprovider for a given service; “deductible” ishow much you pay each year before thedental plan pays; “amount not covered”applies to services/products not coveredby your plan; see “Message Codes” at thebottom of your EOB for details.67891011Total amount eligible for benefits—“charges billed by provider” minus “providerfee adjustment” minus “your copay,deductible or amount not covered.”%—the percentage your plan pays forcovered services.Your coinsurance amount—what youmust pay the provider after we pay thecovered percentage.Adjustment—see explanation(s) at thebottom of your EOB for details.Total benefits from your plan—“totalamount eligible for benefits” minus“your coinsurance amount.”Amount you’re responsible for—whatyou must pay of the billed charges afterplan benefits are paid.Paperless EOBSign up to see your EOB online instead of receiving it by mailwhen you register and log in to premera.com…that’s one lesspiece of paper you’ll have to file away.9

ClaimsFiling a claim when using an out-of-network dentistWhen you see a dentist outside of our network, you may have to pay for the services up frontand submit the claim yourself. (In-network dentists submit the claim for you.)File a claim:1. Download a claim form from the “Forms” sectionon premera.com, and complete.2. Attach an itemized bill from your dentist and proofof payment for the covered service.3. Make a copy for your records.4. Mail your claim to the address on the claim form.Status of a claimLog in to premera.com, go to “My PlanInformation” and check your claim’s status.Question a claimIf you have an issue with a processed claimand would like us to review it, call CustomerService at 800-508-4722. You must make yourrequest within 180 days after you receive yourExplanation of Benefits (EOB).You can also submit a request in writing.Include a copy of the EOB you want reviewedand any other documentation that maysupport your inquiry. Send in this requestwithin 180 days of receiving the EOB to:Premera Blue Cross Blue Shield of AlaskaPO Box 240609Anchorage, AK 99524-0609We’ll send you more details about the reviewprocess once we receive your request.10

Thank youWe are proud to have servedAlaskans for over half a century.Alaskans choose Premera Blue Cross Blue Shield ofAlaska more than any other health plan. We delivercomplete benefit solutions, programs and toolsthat actively promote better health outcomes andhelp achieve sustainable healthcare costs.

This booklet is not a contract. For more information about thefull terms and conditions of your dental plan, including benefits,limitations and exclusions, please see your Benefit Booklet.Note: The sample ID card on the cover may not matchwhat appears on your card.premera.comPremera Blue Cross Blue Shield of Alaska is an IndependentLicensee of the Blue Cross Blue Shield Association022569 (01-2011)