Senior Dental Coverage - Blue Cross Blue Shield of Georgia

SeniorDental CoverageTake Complete Charge of Your Health

Let’s play a gameTrue or False?1. Dental coverage is important to youroverall health and well-being?2. Regular dental check-ups can serveas an early warning sign for healthrelatedissues?3. According to the American DentalHygenist Association, gum and toothdisease have been linked to a numberof major health conditions like heartdisease, stroke, respiratory diseaseand diabetes?Check out the answers belowDid you guess correctly? If so, pat yourselfon the back. Who knew seeing a dentistmay help save your life?We did! And that’s exactly what Blue CrossBlue Shield of Georgia (BCBSGa) had inmind when we created a Dental Plan forseniors. We offer dental coverage to helpyou maintain a healthy smile and youroverall wellness. And it’s affordable, too.Answer Key: 1.T, 2.T, 3.T1

Dental coverage on day oneYou expect coverage for routine checkups,x-rays and cleanings but did youknow that these kinds of procedures arecovered the day your policy is effective?That’s right, day one coverage. No waitneeded.After six continuous months of coverage,you are also covered for more extensiveservices like fillings and extractions.Coverage for major dental care (like rootcanals, crowns and dentures) is effectiveafter 12 continuous months of coverage.Hopefully, you’ll get your cleanings andpreventive care from the beginning andwon’t need to worry about extensive workany time soon.2

Our network of dentists savesyou money.When you choose a contracting dentistor specialist, you’ll get the biggest savings.We still provide benefits when you choosea non-contracting dentist, but your costsmay be higher because our negotiatedfees won’t apply.To find a dentist, simply visit our Web site,www.bcbsga.com and select “F ind a Doctor”which can be found on every page. You cansearch for a specific dentist or a list of nearbydentists, and even print out step-by-step drivingdirections. You can also call our customer caredepartment at (888) 209-7852 Monday throughThursday from 8 a.m. to 10 p.m. and on Fridaysfrom 8 a.m. to 8 p.m.3

Let us help you understandyour benefits.It helps to know exactly what to expectwhen you go to the dentist. That’s why weprovide you with the following information:✓ You do not have to pay a deductible fordiagnostic and preventive services, likecleanings and X-rays.✓ But, you do have an annual $50 perperson deductible before your benefitsbegin for basic and major dental care.✓ Your dental benefits will cover up to$1,000 per member per year.Since you are also responsiblefor charges above the coveredbenefit amounts listed onthe next few pages, it may beimportant to ask in advancehow much your dentistcharges BCBSGa members.Just remember, you mayhave to pay more if you visita non-contracting dentist.4

Diagnostic and Preventive Care• Coverage begins on your effective date.Care is not subject to a deductible.• The benefit schedule is the same for alldentists, but you may pay more if youchoose a non-contracting dentist.• Two oral examinations and two dentalcleanings per member, per year.• Included single and bitewing X-rays not toexceed $47.PROCEDUREPLAN PAYSInitial or Emergency Oral Exam $14Periodic Oral Exam -limited to 2 exams per member per year $14Bitewing X-rays - single film $8Bitewing X-rays - two films $14Single (periapical) X-rays - first film $8Single X-rays - additional films $8Bitewing X-rays - four films $20Full mouth X-rays -limited to one set every 3 years $40Routine Cleaning -limited to 2 per member per year $315

Basic Dental Care• Coverage begins after your Plan has beenin effect for six continuous months.• The rate chart is the same for alldentists, but you may pay more if youchoose a non-contracting dentist.PROCEDUREPLAN PAYSFilling - one surface, permanent $36Filling - two surfaces, permanent $44Filling - three surfaces, permanent $55Filling - four or more surfaces, primary $65Extraction - single tooth (simple) $37Extraction - each additional tooth (simple) $37Surgical Extraction $60Removal of Impacted Tooth -soft tissue $85Removal of Impacted Tooth -partial bony $105Removal of Impacted Tooth -complete bony $1306

Major Dental Care• Coverage begins after the Plan has beenin effect for twelve continuous months.• The benefit schedule is the same for alldentists, but you may pay more if youchoose a non-contracting dentist.PROCEDUREPLAN PAYSScaling/Root Planing per Quadrant $41Gingivectomy or Gingioplasty - per tooth $26Gingivectomy - per quadrant $120Root Canal - 1 canal(excl. Final restoration) $130Root Canal - 2 canals(excl. Final restoration) $155Root Canal - 3 canals(excl. Final restoration) $195Crown (except stainless steel) $215Pontic $215Complete Denture (upper or lower) $255Partial Denture (upper or lower) $235Denture Reline (chair-side) $55Denture Reline (lab) $707

Eligibility and EnrollmentTo be eligible for enrollment, you must be:• 65 years of age or older.• A resident of the State of Georgia whoapplies for coverage and is acceptedby BCBSGa.• A resident of the United States for atleast six months.• Not enrolled under any other individualor group dental policy.Date Coverage BeginsThe effective date of your coverage is printedon your member ID card. Your coverage willstay in effect, with our consent, on a monthlybasis.Terms of CoverageCoverage under this Plan remains in force aslong as the required premiums are paid ontime and as long as the policyholder remainseligible for coverage. BCBSGa has the rightto cancel or modify this Plan or change thepremiums of this Plan after 60 days writtennotice to the policyholder. However,BCBSGa will not cancel or modify this Planon an individual basis, but only for allpolicyholders covered under the same Plan.8

How to EnrollIf you are a new member and want dentalcoverage ONLY:• Complete and sign the attached applicationand Monthly Bank Draft Authorization form.• Send the completed application and bankdraft form along with your first payment toyour agent or the BCBSGa address below.• Remember, BCBSGa dental plan premiumsare payable through the monthly checkingaccount program only.For those applying for BCBSGa medicalcoverage and dental coverage:• Contact your agent or BCBSGa at:1-888-209-7852.For BCBSGa members who want toADD dental:• Complete the attached application.• You must send your first month’s premium($27.00) with the application.• Write a check payable to BCBSGa.• Send the application and payment to youragent or the BCBSGa address below:Blue Cross and Blue Shield of Georgia3350 Peachtree Road, NEMSC GOO302Atlanta, GA 30326Applicants who are approved for enrollment willreceive a BCBSGa Senior Dental Plan Contract.Please review it carefully as it contains specificdetails about your benefits, coverage, exclusionsand limitations. This brochure only provideshighlights of the BCBSGa Senior Dental Plan.This is not the contract and only the actual Planprovisions will apply.9

Conditional ReceiptTHIS RECEIPT DOES NOT PROVIDE ANYCOVERAGE UNTIL ALL THE TERMS ANDCONDITIONS LISTED BELOW ARE MET.DO NOT MAKE CHECKS PAYABLE TO THEAGENT OR LEAVE BLANK.Blue Cross and Blue Shield of Georgia(BCBSGa) has received from the namedApplicant an advance deposit equal to thefirst month’s dues together with anapplication for designated dental insurancecoverage. Such payment is accepted subjectto the following conditions.1. Subject to the provisions of the contract,the coverage applied for will be effectivefrom, and the contract date as of, the dayfollowing acceptance by BCBSGa, unlessotherwise specifically stated, provided thatthe payment evidenced by this receipt isthe full first month’s dues and provided thatBCBSGa determines that as of the date ofthe application all proposed coveredpersons were acceptable for coverage andfor the benefits applied for.2. If the application is not approved byBCBSGa said Plan shall incur no liabilityand the payment evidenced by this receiptwill be refunded to the applicant.3. No one has the authority to waiver ormodify any of the terms and conditions ofthis receipt.10

If you do not receive a contract within 60 days,please contact Blue Cross and Blue Shield ofGeorgia Customer Service Department,PO Box 7368, Columbus, GA 31908-7368.All premium checks must be made payable toBlue Cross and Blue Shield of Georgia.ABBREVIATED NOTICE OF INSURANCEINFORMATION PRACTICESPRIVACY ACTGeorgia state law establishes standards for thecollection, use and disclosure of informationgathered in connection with insurancetransactions. The application attached to thisnotice contains specific personal questionsabout you. We need your answers to decideif you qualify for coverage. We are required toadvise you that personal information may becollected from persons other than you.An investigated consumer report may bemade to help us obtain additional medicaldata from physicians or hospitals.ALL DATA CONFIDENTIALWe are required by law to keep such dataconfidential. It will be seen only by employeesand authorized agents. This data may incertain circumstances be disclosed withoutyour authorization. We may furnish suchdata to authorized federal or state agencies,consumer investigative service bureaus orothers if part of our standard businesspractice or required by law.11

ACCESS TO YOUR DATAYou have the right to see or obtain a photocopyof your personal information, which we have.You also have the right to send us a writtenrequest if you want any of your personalinformation to be amended, corrected ordeleted. If you wish to have a more detailedexplanation of our information practices,please contact:Blue Cross and Blue Shield of GeorgiaCustomer Service Department,PO Box 7368,Columbus, GA 31908-7368.12

In order to keep your dentalcoverage affordable, there arecertain limitations and exclusionsthat will be listed on the contractyou get after enrolling. If you wouldlike to review a detailed list, pleaselog on to the member section of ourWeb site, www.bcbsga.com andclick “Plans & Benefits”, “DentalPlans”, “Senior”, then “DentalExclusions and Limitations.”Monthly Rate is $27.**Rate subject to change.13

Sign me up.To enroll, simply complete the dentalapplication and include the firstmonth’s premium. Mail items to:Blue Cross Blue Shield of Georgia3350 Peachtree Road, NEMSC G00302Atlanta, GA 3032614

Blue Cross Blue Shield of Georgia3350 Peachtree Road, N.E.Atlanta, GA 30326Telephone 1-888-209-7852www.bcbsga.comBlue Cross Blue Shield of Georgia is an Independent Licensee of theBlue Cross Blue Shield Association. The Blue Cross and Blue Shield namesand symbols are registered marks of the Blue Cross Blue Shield Association© Blue Cross Blue Shield of GeorgiaSM Service Mark of the Blue Cross Blue Shield Association11077 5/07MBUID6-104-00