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CareFirst BlueCross BlueShield Dental Insurance

CareFirst BlueCross BlueShield Dental Insurance Plans for Individuals

- Easy enrollment – No deductibles – Predictable out-of-pocket costs

- No claims forms to file – Guaranteed acceptance

 

Both these Dental Plans have been very popular in Maryland because they are affordable and provide access to quality dental services by top local dentists. Included are preventive services to maintain optimal oral health and discounted rates for basic and major services. Please refer to the benefits brochure for each plan below.

These dental policies by CareFirst Blue Cross Blue Shield can become effective on the first day of each month

Individual Select Preferred Dental Plan (PPO Plan)
Individual Select Denta HMO Plan

Coverage Type

Annual RateFull Annual Payment Due with Enrollment Application

Individual

$189.72

Individual & Child

$251.00

Individual & Adult

$436.56

Family

$531.36
Get Application Form
View and Print - Dental Application Form For CareFirst Blue Cross PPO Maryland

 

Please note that the ONLY way to apply is to Print and Fill Out the Application Form and Mail it along with the payment Check to the address indicated on the application Form. Your application must be received by the 24th day of the month in order to get the effective date of the 1st day of the next month.

Coverage Type

Annual Rate

Full Annual Payment Due with Enrollment Application

Individual

$120

Individual & Child

$204

Individual & Adult

$240

Family

$360

Print  Application Form and Apply for  The CareFirst Blue Cross Blue Shield Dental HMO Plan

.

Please note that the ONLY way to apply is to Print and Fill Out the Application Form and Mail it along with the payment Check to the address indicated on the application Form. Your application must be received by the 24th day of the month in order to get the effective date of the 1st day of the next month.

Please note thatwhen selecting the semi-annualpayment ,a $5.00 administrative feeisal ready included in eachpayment. You pay an additional $10 / year when you select the semi-annual payment option. The firstpayment (ofthesemi-annualrate) is due with the enrollment application.

The second payment is due by the first of the seventh month from the effective date of coverage.For example, if coverage iseffective January1, the second payment is due July1

 

 

Benefits at a Glance

 

More than 3,400 dentists throughout Maryland, DC and Northern Viriginia
What Your Plan Covers

 

In-Network

As a member you’ll receive 100 % coverage innetwork

for preventive and 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.

 

Out-of-Network

You also have the option to seek routine preventive

and diagnostic treatment from Non-Participating

Providers. If you visit a Non-participating Provider,

CareFirst will still pay the Allowed Benefit, but

you will be responsible for the difference in cost

between the CareFirst Allowed benefit and your

dental provider’s full charge.

 

Allowed Benefit*The Allowed Benefit is typically a reduced raterather than the actual charge. For example: Youhave just visited your dentist for a routine examand cleaning. The total charge for the visit comesto $125. If the doctor is a participating providerthey may be required to accept $75 from CareFirstas payment in full for the visit—this is the Allowed

Benefit. If, however, the dental provider you visit is

non-participating then you may be held

responsible for the difference between the

CareFirst Allowed Benefit and the Dental

Provider’s full charge.

Exclusions and Limitations.

 

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 the Subscriber’s Agreement 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.

 

Please see the brochure for details of the benefits

Benefits at a Glance
-Lower cost- More than 800 dentists throughout Maryland, DCand Northern Virginia
 
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.

 

 

 

 

 

 

 

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

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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