Senior Dental Coverage - Blue Cross Blue Shield of Georgia

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