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More than 3,400 dentists throughout Maryland, DC and Northern Viriginia
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| What Your Plan Covers |
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100% Coverage In-Network for Preventive & Diagnostic Services
Individual Select Preferred combines the freedom to select any dentist from our large regional network with wide-ranging coverage of preventive and diagnostic dental services.
The following are some of the services which are covered in full when visiting an in-network provider:
- Examinations
- Cleanings – X-rays - Sealants - Fluoride treatments for children
Participating dentists accept 100% of the Allowed Benefit from CareFirst as payment in full for covered services.
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Limitations.
A. Covered Dental Services must be performed by or under the supervision of a Dentist, within the scope of practice for which licensure or certification has been obtained.
B. Benefits will be limited to standard procedures and will not be provided for personalized restorations or specialized techniques.
Exclusions. Benefits will not be provided for:
A. Additional fees charged for visits by a Dentist to the Member’s home, to a hospital, to a nursing home, or for office visits after the Dentist’s standard office hours. CareFirst shall provide the benefits for the dental service as if the visit was rendered in the Dentist’s office during normal office hours.
B. Services not specifically listed in this Attachment as a Covered Dental Service, even if Medically Necessary.
C. Services or supplies that are related to an excluded service (even if those services or supplies would otherwise be covered services).
D. Separate billings for dental care services or supplies furnished by an employee of a Dentist which are normally included in the Dentist’s charges and billed for by them.
E. Telephone consultations, failure to keep a scheduled visit, completion of forms, or administrative services.
F. Services or supplies that are Experimental or Investigational in nature.
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>* Based on National Dental Advisory Service Fee Report (2006). >
This portion of the plan is not an insurance product. Member charges are based on Individual Select Preferred allowances with > >the participating providers. Since rates vary by provider, members should check with their participating dentist to determine > >the costs of specific procedures. Members must pay these reduced rates directly to the provider during the office visit.
Please see the brochure for details of the benefits
Important Notice
Based on the passing of Maryland Senate Bill 705, beginning on October 1, 2011, all participating dentists, dental specialists, and oral surgeons in your Individual Select Preferred dental plan will no longer be required to accept the allowed amount (discount) as payment in full for non-preventive services. Examples of these services include fillings, extractions, root canals, crowns, and orthodontics. You should check with your participating dentist to determine whether (s)he will continue to honor the allowed amount (discount) for non-preventive services. Please note that this legislative change does not impact covered services such as exams, cleanings and X-rays, which will continue to be paid at 100% when you use an in-network provider. For more details about covered services, please refer to the booklet you received with your dental identification card, titled “Dental Plan Benefit Information” for your Individual Select Preferred dental plan. Should you have additional questions about the content of this letter, please call Dental Business Operations Member Services at (888) 833-8464 between 8:30 a.m. – 5:00 p.m., Monday through Friday.
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Benefits at a Glance
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-Lower cost- More than 800 dentists throughout Maryland, DCand Northern Virginia
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| Preventive check-ups (includesroutineexams,cleaningsandX-rays) |
$165 pervisit
(2 visitsperyear) |
$20per
officevisit |
| Basic Dental Services (includesfillings,simpleextractionsandmore) |
$130–$320 |
$20 per
officevisit |
| Soft Tissue Management (includesperiodontalscaling,periodontal maintenanceandmore) |
$240 |
$70 per
officevisit |
| Root Canal Therapy Bicuspid (excludesfinalrestoration) |
$800 |
$375 Primary Dentistor $475 SpecialtyCare Dentist |
| Complete Upper Dentures |
$1,595 |
$495 |
| Orthodontia (Braces) Comprehensive -Adolescent Comprehensive -Adult |
$5,045 $5,020 |
$2,500 $2,700 |
Please see the brochure for details of the benefits
ExclusionsandLimitations
MARYLAND
PLAN LIMITATIONS.The following exclusions and limitations shall apply:
Services for injuries and conditions which are covered under Workers’ CompensationorEmployers’LiabilityLaws;
Services which are provided without cost to the Covered Individual and/or Dependent(s) by any municipality,county or otherpolitical subdivision (withthe exceptionof Medicaid);
Services which, in the opinion of the Participating DENTIST, are not necessary for the Covered Individual and/or Dependent(s) health;
Payment of any claim or bill will not be made for prohibited referrals; Cosmetic, elective, or aesthetic dentistry, which in the opinion of the Participating DENTIST are not necessary for the patient’s dental health; Oral surgery requiring the setting of fractures or dislocations; Services with respect to malignancies, cystsorneoplasms, or hereditary, congenital or developmental malformations; Dispensing of drugs, except those used as a localanesthetic; Hospitalization for any dental procedure; Loss or theft of bridgework or dentures previously supplied under the PLAN; Replacement of a bridge, crown, or denture within five (5) years after the date it was originally installed;
Any implantation; General anesthesia; Services that cannot be performed because of the general health of the patient; Teeth Cleaning (Prophylaxis) limited to twice per Coverage Period; Unlisted procedures will be provided at the dentist’s charge; Services which are obtained outside the dental office in which enrolled and
which are not pre-authorized by the PLAN. This does not apply to out-of-area emergency dental services;
Services rendered by a Pedodontist (PediatricDentist) are considered Specialty Care and must be approved by the Covered Individual and / or Dependent(‘s) Personal Participating DENTIST; all services listed on the Schedule of Benefits and Copayments will be provided by a general Participating DENTIST or an Approved Specialist ; provided, however, that a general DENTIST will refer the Covered Individual or Dependent to an Approved Specialist or recommend that the Covered Individual or Dependent contact an Approved Specialist if it is the judgment of the DENTIST that the service or procedure must be provided by an Approved Specialist, with an exception for out-of-area emergencycare, and a referral to a non-participating general dentist or specialist;
Services which cannot be performed in the dental office of the “Personal Participating DENTIST ”or“ Approved Specialist” due to the special needs or health related conditions of the Covered Individual and/or Dependent(s).
OUT-OF-AREA EMERGENCY CARE: Covered Individuals and/or Dependents are covered for emergency dental treatment to alleviate acutepain, along with treatment arising from accidental injury or illness while temporarily more than fifty (50) miles from their “Personal ParticipatingDENTIST. ”Limited to $50 per Covered Individual or Dependent per emergency, minus member’scopay.
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PPO Plan Application Instructions
CareFirst Blue Cross Blue Shield is not currently processing online applications for these products – To apply you MUST:
- Download and Print the application form
- Fill the form and mail it to the address specified on the form
- Be sure to include the full payment in check or money order
-Once your application has been received and processed, your benefits will begin on the First Day of the following month.
-If you have submitted your application and you have allowed 10 business days for processing and have not yet received your card. Please make sure that your check has cleared then call (888) 833-8464
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HMO Plan Application Instructions
CareFirst BlueCross BlueShield is not currently processing online applications for these products – To apply you MUST:
- Download and Print the application form
- Fill the form and mail it to the address specified on the form
- Be sure to include the full payment in check or money order
-Once your application has been received and processed, your benefits will begin on the First Day of the following month.
-If you have submitted your application and you have allowed 10 business days for processing and have not yet received your card. Please make sure that your check has cleared then call (888) 833-8464
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