Our Dental Plan For Individuals and Families

Dental Plan Information
Our dental plan for individuals and families
WHAT YOU GET
Low premiums, easy payment options Checkups and cleanings covered twice per benefit period No deductible and no waiting for preventive services Coverage for fillings, gum treatments, crowns and more Expansive network Coverage for you and your family
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Quality coverage
for individuals and families
Protect your overall health
Medical experts have linked periodontal (gum) disease to stroke, heart disease, diabetes, pre-term or low-birth-weight babies and other health issues. Nearly 75 percent of American adults have some form of periodontal disease.1 But with proper daily dental care, regular dental checkups can help detect, prevent and treat gum disease and related disorders. Choose Dental Blue for Individuals and you can take a big step toward protecting your overall health. HOW IT WORKS FOR YOU
A network of qualified dentists

Its easy to find a dentist you can trust, even if youre out of town, with our broad, local and national network. Though youre free to visit any licensed dentist you choose, there are distinct advantages to visiting a dentist in our network: + oure not responsible for charges over the allowed Y amount for covered services. + ental claims will be filed for you, saving you time D and trouble. + entists in our network have been credentialed D and approved. To find a dentist, go to bcbsnc.com and click on Find a Doctor.
Coverage you can smile about

With Dental Blue for Individuals, youre covered for a broad range of dental services, including routine fillings and extractions, plus major services like crowns, bridges and dentures. Coverage includes preventive care. That means you can get checkups and cleanings twice per benefit period, and that translates into good oral health. And, there are no waiting periods for cleanings, routine oral exams and other diagnostic and preventive services.
Individual or family coverage

Dental Blue for Individuals offers a plan for every budget. You can cover yourself, your child, even your whole family.
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Visit
Get Dental Blue for Individuals
SM
Contact your authorized agent to apply for Dental Blue for Individuals today. Residents of North Carolina are eligible for Dental Blue for Individuals.2 If your application is received by the 8th of the month, your coverage can begin as soon as the 15th of that same month. If your application is received by the 22nd of the month, your coverage can begin as soon as the 1st of the following month. Requested effective dates may not be more than 60 days from the date you submit your application.
bcbsnc.com
Dental Blue for Individuals Benefits Type of coverage
Preventive services
Routine oral exams and cleanings, bitewing X-rays, sealants (for members 6 to 15 years old only), space maintainers (for members under 16 years old only), pulp testing, fluoride treatment (for members through 18 years old only), palliative emergency treatment at the dentist, emergency oral examinations at the dentist, other diagnostic and preventive services3 Fillings, endodontics, simple extractions, oral surgery and other basic services3
Plan benefits
100%
Basic services Major services
60%
Gingival curettage, gingivectomy and gingivoplasty, periodontal maintenance, inlays and onlays (once per 8 years), crowns and bridges, dentures and other major services3
50% $1,000 None/6 months/12 months $75
(per covered member)
Annual maximum for all services4
Waiting periods Deductible
Preventive services/basic services/major services Basic and major services
Limitations & Exclusions

This is a partial list of services that are not covered by Dental Blue for Individuals. Refer to the member booklet for a full list of exclusions. Your coverage may be canceled by Blue Cross and Blue Shield of North Carolina for failure to pay premiums when due and for fraudulent statements on your application, among other reasons. Members will be notified 30 days in advance of any change in coverage. Consult your member guide for complete information. Your dental benefits plan does not cover services, supplies, drugs or charges that are:
Orthodontic services Not clinically necessary Investigational in nature or obsolete, including any service, drugs, procedure or treatment directly related to an investigational treatment Not prescribed or performed by or upon the direction of a dentist or other provider Received prior to the members effective date Received on or after the coverage termination date, regardless of when the treated condition occurred or whether the care is a continuation of care received prior to the termination For telephone consultations, failure to keep a scheduled visit, completion of a claim form, obtaining dental records, and late payments Incurred more than 18 months prior to members submission of a claim to BCBSNC For complications or side effects arising from services, procedures or treatments excluded from coverage under this dental benefits plan Provided and billed by a licensed dental care professional who is in training Available to a member without charge For care given to a member by a provider who is in the members immediate family In excess of the allowed amount5
1 The Health Perils of Gum Disease. Dulce Zamora, April 2005. Reviewed by Brunilda Nazario, MD; www.webmd.com/content/article/104/107269.htm; Reviewed April 2010 (Accessed June 2011). 2 If youve terminated a Dental Blue for Individuals policy within the last 12 months, you are ineligible for coverage. 3 Refer to the member booklet for a full list of diagnostic and preventive, basic and major services. 4 Based on allowed amount. Annual maximum on all services is $1,000 (includes diagnostic and preventive, basic and major services). 5 Allowed amount is 90th percentile of the BCBSNC fee schedule. , SM Marks of the Blue Cross and Blue Shield Association. Blue Cross and Blue Shield of North Carolina is an independent licensee of the Blue Cross and Blue Shield Association. BE40, 9/11
Policy Form #M60 8/09
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Our Dental Plan For Individuals and Families

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Dental Plan Information

Our dental plan for individuals and families

WHAT YOU GET

A network of qualified dentists

Coverage you can smile about

Individual or family coverage

Get Dental Blue for Individuals

Basic services Major services

50% $1,000 None/6 months/12 months $75

(per covered member)

Annual maximum for all services4

Waiting periods Deductible

Preventive services/basic services/major services Basic and major services

Limitations & Exclusions

Policy Form #M60 8/09

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