Blue Shield Dental PPO Smile Plans and Dental HMO Plans Producer information for groups of 2 to 50 Effective July 1, 2008 Dental coverage is one of the most requested employee benefits.1 Blue Shield makes dental easy to sell by offering a wide range of affordable coverage choices to fit your clients’ specific needs and budgets.

Advantages of Dental PPO Smile plans

Advantages of dental HMO plans

With our Dental PPO SmileSM plans, members have access to one of the largest dental PPO networks in California and thousands more providers nationwide.2

For your cost-conscious clients, offer one of our dental HMO plans priced to fit their budget.

• One of the largest provider networks with more than 19,000 provider access points in California, and more than 75,000 nationwide.2

• No waiting periods for most services and virtually no claim forms • No deductibles and no calendar-year maximums

• Single-source account administration when sold with a Blue Shield health plan.

• No charge for routine diagnostic and preventive services such as full-mouth X-rays, cleanings and sealants

• Orthodontic coverage options for children and adults, with up to a $1,000 orthodontic coverage per member, per calendar year.

• Access to more than 1,300 dental HMO facilities (with 8,600 dental provider access points) in California

• Enhanced dental services for pregnant women.

• Orthodontic coverage for children and adults • Low $5 office visit copayments

We also offer a dental HMO voluntary plan and a dental PPO voluntary plan. Please note that dental plans are not available with Access Baja® HMO plans.

blueshieldca.com

Plan availability

What the dental PPO plans cover

We offer four dental HMO plans and 10 dental PPO plans that are available to groups with or without enrollment in a Blue Shield health plan. Non-voluntary dental plans require a 50% employer contribution and 75% employee participation (reduced participation for Suite Deal Dental, see below). Voluntary dental plans have no employer contribution or employee participation requirements.

Each of our 10 Dental PPO Smile plans covers a broad range of services, from network or non-network dentists. Members can save money by choosing a network dentist. Benefits are paid based on percentages of the Maximum Allowable Charge (MAC) or 85th percentile of Usual Customary and Reasonable (UCR) fees, as shown in the following table.

Suite Deal Dental Suite Deal Dental is a package of five dental plans with lower participation guidelines. • Dental PPO Smile Basic • Dental PPO Smile Value • Dental PPO Smile Deluxe Plus 2000 • Dental HMO Basic • Dental HMO Plus

MAC is the amount that in-network providers have agreed to accept as payment in full for a specific procedure. An out-of-network provider may charge more. Members are responsible for any amount that exceeds those charges. The UCR rate is the cost for a typical service within a specified region. UCR fee schedules differ by region, depending on where your clients receive services. If your clients go to a non-network dentist, they pay the amount above the UCR reimbursement rate.

All dental PPO plans also offer: • Network and non-network benefits

Suite Deal Dental is available with any Blue Shield health plan or on a standalone basis.

• No waiting period for most services, including major services and annual diagnostic and preventive care

A total of 65% of all eligible employees must participate. All five plans must be offered to employees but participation in all plans is not required.

• Dedicated customer service team that your clients can call toll-free

Dual Option Clients can provide their employees with a choice between any two dental plans, including dental PPO and dental HMO plans. Any of these combinations can include voluntary plans. Employer contribution and participation requirements may vary depending on the two plans selected.

Dependent enrollment guideline

• Easy-to-use online dental provider directory at blueshieldca.com

How dental HMO plans work Dental care is accessed through a large network of dental providers. At enrollment time, members choose a Blue Shield network dental provider from the Dental HMO Provider Directory, available at blueshieldca.com. The selected primary dental provider will coordinate all covered general, specialty, and emergency dental care. Members have the option to change dental providers during the year.

When dental PPO is sold with a Blue Shield health plan, and subscribers elect to enroll in both, they can choose whether to enroll all, some, or none of their dependents in a dental PPO plan.

2 

Dental PPO and HMO Producer Brochure

Blue Shield Dental PPO Plans Smile Basic Voluntary 75/1000/No Ortho/MAC3 Network Deductible Calendar-year maximum

Non-network5 $75/person, $225/family

$1,000 ($750 may be used for non-network dentists)

Orthodontic care − all ages (up to $1,000/calendar year),

Not covered

the calendar-year maximum for orthodontics is in addition to the calendar-year maximum for other covered services

Diagnostic and preventive care (not subject to plan deductibles with network dentists; includes routine oral exams and X-rays, cleanings)

100%

50%

Enhanced dental services for pregnant women7 (not subject

100%

100%

50%

50%

Endodontics, periodontics, and oral surgery

50%

50%

Major services (includes crown buildups, crowns, prosthetics,

50%

50%

Network

Non-network5

to plan deductibles with network dentists)

Basic services (includes anesthesia, emergency treatment to relieve pain, restorative dentistry, sealants, space maintainers)

inlays, onlays, jackets, oral surgery, posts and cores, veneers)

Smile Basic 75/1000/No Ortho/MAC Deductible Calendar-year maximum

$75/person, $225/family $1,000 ($750 may be used for non-network dentists)

Orthodontic care − all ages (up to $1,000/calendar year),

Not covered

the calendar-year maximum for orthodontics is in addition to the calendar-year maximum for other covered services

Diagnostic and preventive care (not subject to plan deductibles with network dentists; includes routine oral exams and X-rays, cleanings)

100%

50%

Enhanced dental services for pregnant women7 (not subject

100%

100%

50%

50%

Endodontics, periodontics, and oral surgery

50%

50%

Major services (includes crown buildups, crowns, prosthetics,

50%

50%

Network

Non-network5

to plan deductibles with network dentists)

Basic services (includes anesthesia, emergency treatment to relieve pain, restorative dentistry, sealants, space maintainers)

inlays, onlays, jackets, oral surgery, posts and cores, veneers)

Smile Value 50/1500/No Ortho/MAC Deductible Calendar-year maximum

$50/person, $150/family $1,500 ($750 may be used for non-network dentists)

Orthodontic care − all ages (up to $1,000/calendar year),

Not covered

the calendar-year maximum for orthodontics is in addition to the calendar-year maximum for other covered services

Diagnostic and preventive care (not subject to plan deductibles with network dentists; includes cleanings, routine oral exams and X-rays)

100%

80%

Enhanced dental services for pregnant women7 (not subject

100%

100%

80%

70%

Endodontics, periodontics, and oral surgery

50%

50%

Major services (includes crown buildups, crowns, prosthetics,

50%

50%

to plan deductibles with network dentists)

Basic services (includes anesthesia, emergency treatment to relieve pain, restorative dentistry, sealants, space maintainers)

inlays, onlays, jackets, oral surgery, posts and cores, veneers)

Dental PPO and HMO Producer Brochure

3

Smile Plus Gold 50/1500/Ortho/U852 Network Deductible Calendar-year maximum Orthodontic care − all ages (up to $1,000/calendar year),

Non-network5 $50/person, $150/family

$1,500 ($1,000 may be used for non-network dentists) 50%

50%

Diagnostic and preventive care (not subject to plan deductibles with network dentists; includes cleanings, routine oral exams and X-rays)

100%

80%

Enhanced dental services for pregnant women7 (not subject

100%

100%

80%

70%

Endodontics, periodontics, and oral surgery

50%

50%

Major services (includes crown buildups, crowns, prosthetics,

50%

50%

Network

Non-network5

the calendar-year maximum for orthodontics is in addition to the calendar-year maximum for other covered services

to plan deductibles with network dentists)

Basic services (includes anesthesia, emergency treatment to relieve pain, restorative dentistry, sealants, space maintainers)

inlays, onlays, jackets, oral surgery, posts and cores, veneers)

Smile Deluxe 2000 50/2000/No Ortho/MAC Deductible Calendar-year maximum

$50/person, $150/family $2,000 (may be used for both network and non-network dentists)

Orthodontic care − all ages (up to $1,000/calendar year),

Not covered

the calendar-year maximum for orthodontics is in addition to the calendar-year maximum for other covered services

Diagnostic and preventive care (not subject to plan deductibles with network dentists; includes cleanings, routine oral exams, and X-rays)

100%

100%6

Enhanced dental services for pregnant women7 (not subject

100%

100%6

80%

80%

Endodontics, periodontics, and oral surgery

80%

80%

Major services (includes crown buildups, crowns, prosthetics,

50%

50%

Network

Non-network5

to plan deductibles with network dentists)

Basic services (includes anesthesia, emergency treatment to relieve pain, restorative dentistry, sealants, space maintainers)

inlays, onlays, jackets, oral surgery, posts and cores, veneers)

Smile Deluxe Plus 2000 50/2000/Ortho/MAC Deductible Calendar-year maximum Orthodontic care − all ages (up to $1,000/calendar year),

$50/person, $150/family $2,000 (may be used for both network and non-network dentists) 50%

50%

Diagnostic and preventive care (not subject to plan deductibles with network dentists; includes cleanings, routine oral exams, and X-rays)

100%

100%6

Enhanced dental services for pregnant women7 (not subject

100%

100%6

80%

80%

Endodontics, periodontics, and oral surgery

80%

80%

Major services (includes crown buildups, crowns, prosthetics,

50%

50%

the calendar-year maximum for orthodontics is in addition to the calendar-year maximum for other covered services

to plan deductibles with network dentists)

Basic services (includes anesthesia, emergency treatment to relieve pain, restorative dentistry, sealants, space maintainers)

inlays, onlays, jackets, oral surgery, posts and cores, veneers)

4 

Dental PPO and HMO Producer Brochure

Smile 50/1500/No Ortho/MAC Network Deductible Calendar-year maximum

Non-network3 $50/person, $150/family

$1,500 ($750 may be used for non-network dentists)

Orthodontic care − all ages (up to $1,000/calendar year),

Not covered

the calendar-year maximum for orthodontics is in addition to the calendar-year maximum for other covered services

Diagnostic and preventive care (not subject to plan deductibles with network dentists; includes cleanings, routine oral exams, and X-rays)

100%

80%

Enhanced dental services for pregnant women7 (not subject

100%

100%

80%

70%

to plan deductibles with network dentists)

Basic services (includes anesthesia, emergency treatment to relieve pain, restorative dentistry, sealants, space maintainers)

Endodontics, periodontics, and oral surgery

80%

70%

Major services (includes crown buildups, crowns, prosthetics,

50%

50%

Network

Non-network5

inlays, onlays, jackets, oral surgery, posts and cores, veneers)

Smile Plus 50/1500/Ortho/MAC Deductible Calendar-year maximum Orthodontic care − all ages (up to $1,000/calendar year),

$50/person, $150/family $1,500 ($750 may be used for non-network dentists) 50%

50%

Diagnostic and preventive care (not subject to plan deductibles with network dentists; includes cleanings, routine oral exams, and X-rays)

100%

80%

Enhanced dental services for pregnant women7 (not subject

100%

100%

80%

70%

the calendar-year maximum for orthodontics is in addition to the calendar-year maximum for other covered services

to plan deductibles with network dentists)

Basic services (includes anesthesia, emergency treatment to relieve pain, restorative dentistry, sealants, space maintainers)

Endodontics, periodontics, and oral surgery

80%

70%

Major services (includes crown buildups, crowns, prosthetics,

50%

50%

inlays, onlays, jackets, oral surgery, posts and cores, veneers)

Smile Deluxe 50/1500/Ortho/MAC & Smile Deluxe Gold 50/1500/Ortho/U854 Network Deductible Calendar-year maximum Orthodontic care − all ages (up to $1,000/calendar year),

Non-network5 $50/person, $150/family

$1,500 (may be used for both network and non-network dentists) 50%

50%

Diagnostic and preventive care (not subject to plan deductibles with network dentists; includes cleanings, routine oral exams, and X-rays)

100%

100%6

Enhanced dental services for pregnant women7 (not subject

100%

100%6

80%

80%

Endodontics, periodontics, and oral surgery

80%

80%

Major services (includes crown buildups, crowns, prosthetics,

50%

50%

the calendar-year maximum for orthodontics is in addition to the calendar-year maximum for other covered services

to plan deductibles with network dentists)

Basic services (includes anesthesia, emergency treatment to relieve pain, restorative dentistry, sealants, space maintainers)

inlays, onlays, jackets, oral surgery, posts and cores, veneers)

Dental PPO and HMO Producer Brochure

5

What the dental HMO plans cover Blue Shield dental HMO plans give members access to an extensive network of dental providers that agree to bill at lower, negotiated rates. The chart below provides a list of copayments for some of the most common procedures by American Dental Association (ADA) codes.

Blue Shield Dental HMO Plans

ADA code

Service/benefit

9999

Office visit

Dental HMO Basic member copayment

Dental HMO Voluntary member copayment

Dental HMO Plus member copayment

Dental HMO Deluxe member copayment

$5

$5

$5

$5

Diagnosis 0120/0150

Dental examination (routine)

No charge

No charge

No charge

No charge

0270/0272 0274/0277

Bitewing X-rays (as necessary)

No charge

No charge

No charge

No charge

0330/0210

Full mouth X-rays or panographic X-rays (as necessary)

No charge

No charge

No charge

No charge

0220/0230 0240

Periapical or occlusal X-rays (as necessary)

No charge

No charge

No charge

No charge

0460

Pulp vitality tests

No charge

No charge

No charge

No charge

0470

Diagnostic casts

No charge

No charge

No charge

No charge

0474-0480 0502

Histopathologic (laboratory) Examinations/Procedures

No charge

No charge

No charge

No charge

Specialist consultation (as necessary)

No charge

No charge

No charge

No charge

9310

Preventive 1110/1120

Prophylaxis (cleaning and scaling)

No charge

No charge

No charge

No charge

1203

Fluoride treatment (eligible member to age 19)

No charge

No charge

No charge

No charge

1330

Oral hygiene & dietary instruction

No charge

No charge

No charge

No charge

Sealants (per tooth) (eligible member to age 19)

No charge

No charge

No charge

No charge

1351

Restorative (includes local anesthetic) 2140/2161

Amalgam restorations for treatment of caries

$20 per surface

$15 per surface

$10 per surface

No charge

2330/2331 2332/2335

Plastic or composite restorations for treatment of caries (anterior only)

$20 per surface

$15 per surface

$10 per surface

No charge

Plastic or composite restorations for treatment of caries (posterior only) 2391

1 surface posterior composite

$75

$71

$64

$61

2392

2 surface posterior composite

$90

$85

$76

$72

2393

3 surface posterior composite

$115

$109

$98

$93

2394

4 or more surfaces posterior composite

$140

$133

$120

2740/2783

Porcelain crowns (anterior through 2nd bicuspid only)

$350 each crown*

$250 each crown*

$150 each crown*

$125 each crown*

2750/2751 2752

Porcelain with metal crowns (anterior through 2nd bicuspid only)

$350 each crown*

$250 each crown*

$150 each crown*

$125 each crown*

2780/2781 2782/2790 2791/2792 2794

Metal crowns

$350 each crown*

$250 each crown*

$150 each crown*

$125 each crown*

$114

2920

Recementation of crown

$15

$10

$5

$5

2930

Prefabricated stainless steel crown – Primary tooth

$30

$20

$10

$5

$25 per tooth

$20 per tooth

$10 per tooth

$5 per tooth

$75 per quadrant

$40 per quadrant

$20 per quadrant

$10 per quadrant

2951

Pin buildup

Periodontics (includes local anesthetic) 4341

6 

Scaling and root planing per quadrant (four or more)

Dental PPO and HMO Producer Brochure

Blue Shield Dental HMO Plans

ADA code

Service/benefit

Dental HMO Basic member copayment

Dental HMO Voluntary member copayment

Dental HMO Plus member copayment

Dental HMO Deluxe member copayment

$38

$20

$10

$5

$200 per quadrant

$150 per quadrant

$100 per quadrant

$75 per quadrant

$40 per tooth

$30 per tooth

$20 per tooth

$15 per tooth

$275 per quadrant

$225 per quadrant

$150 per quadrant

$125 per quadrant

Periodontics (includes local anesthetic) 4342

Scaling and root planing (1-3 teeth)

4210

Gingivectomy/gingivoplasty (4 or more teeth)

4211

Gingivectomy/gingivoplasty (1-3 teeth)

4260

Osseous surgery (4 or more teeth)

4261

Osseous surgery (1-3 teeth)

9951/9952

Equilibration

$138

$113

$75

$63

$150 entire mouth

$125 entire mouth

$50 entire mouth

$25 entire mouth

Prosthetics 5110/5120 5130/5140

Full upper or lower denture (includes adjustments for first 6 months post insertion)

$400 per denture

$250 per denture

$175 per denture

$100 per denture

5211/5212 5213/5214

Upper or lower partial denture w/metal lingual or palatal bar, clasps and acrylic saddles or base (includes adjustments for first 6 months post insertion)

$450 per denture*

$275 per denture*

$200 per denture*

$175 per denture*

5225/5226

Upper or lower partial denture flexible base, including clasps, rests and teeth (includes adjustments for first 6 months post insertion)

$450 per denture

$275 per denture

$200 per denture

$175 per denture

5510/5520/ 5610

Denture repair (office)

$100

$75

$50

$25

5510/5520 5610/5620/ 5640

Denture repair (laboratory)

$125

$100

$75

$50

5650

Add tooth to existing partial denture

$100

$75

$50

$25

5660

Add clasp to existing partial denture

$125

$100

$50

$25

5730/5731 5740/5741

Denture reline – chairside

$125 per denture

$100 per denture

$50 per denture

$25 per denture

5750/5751 5760/5761

Denture reline – laboratory

$150 per denture

$125 per denture

$75 per denture

$50 per denture

5820/5821

Temporary partial stayplate (includes teeth and clasps)

$125

$100

$50

$25

5850/5851

Tissue conditioning

$30 per denture unit

$20 per denture unit

$10 per denture unit

$5 per denture unit

1510/1515 1520/1525

Space maintainers (for primary teeth)

$40 per tooth

$20 per tooth

$10 per tooth

$5 per tooth

6750/6751/ 6752

Bridge abutments or pontics (per unit, includes local anesthetic) Porcelain with metal crowns (anterior through 2nd bicuspid only)

$350 each crown*

$250 each crown*

$150 each crown*

$125 each crown*

6780/6781 6782/6790 6791/6792/ 6794

Metal crowns

$350 each crown*

$250 each crown*

$150 each crown*

$125 each crown*

6210/6212/ 6214 6240/6242

Pontics

$350 each tooth replaced*

$250 each tooth replaced*

$150 each tooth replaced*

$125 each tooth replaced*

6930

Recement bridge

$30

$20

$10

No charge

6980

Bridge repair procedure

Lab + $30

Lab + $20

Lab + $10

Lab + $5

$125 in addition to crown*

$100 in addition to crown*

$75 in addition to crown*

$50 in addition to crown*

Endodontics (includes local anesthetic) 2952/6970

Cast post and core

Dental PPO and HMO Producer Brochure

7

Blue Shield Dental HMO Plans

ADA code

Service/benefit

Dental HMO Basic member copayment

Dental HMO Voluntary member copayment

Dental HMO Plus member copayment

Dental HMO Deluxe member copayment

$125 in addition to crown*

$100 in addition to crown*

$50 in addition to crown*

$25 in addition to crown*

Endodontics (includes local anesthetic) 2954/6972

Prefabricated post and core

2915

Recement cast or prefabricated post and core

$5

$5

$5

$5

3110/3120

Pulp capping

$20

$15

$5

No charge

3220

Pulpotomy

$35

$30

$10

$5

3310/3346

Root canal filling (anterior tooth)

$175

$125

$75

$50

3320/3347

Root canal filling (bicuspid tooth)

$350

$175

$105

$70

3330/3348

Root canal filling (molar tooth)

3410/3421 3425

Apicoectomy (anterior/bicuspid/molar)

3426

Apicoectomy (bicuspid/molar)

3920

Hemisection (not including root canal)

$525

$225

$135

$90

$75 first root

$50 first root

$30 first root

$20 first root

$75 each additional root

$50 each additional root

$30 each additional root

$20 each additional root

$125

$100

$50

$25

Oral surgery (includes local anesthetic) 7140

Routine extraction

$40 per tooth

$23 per tooth

$11 per tooth

$6 per tooth

7111

Routine removal of coronal remnants

$20 per tooth

$10 per tooth

$5 per tooth

$3 per tooth

7210

Surgical removal

$75 per tooth

$45 per tooth

$25 per tooth

$15 per tooth

7220

Removal of tooth (soft tissue impaction)

$100 per tooth

$50 per tooth

$30 per tooth

$20 per tooth

7230

Removal of tooth (partial bony impaction)

$150 per tooth

$75 per tooth

$50 per tooth

$40 per tooth

7240/7241

Removal of tooth (complete bony impaction)

$225 per tooth

$95 per tooth

$75 per tooth

$65 per tooth

7310/7320

Alveoloectomy with/without extractions

$75 per quadrant

$60 per quadrant

$40 per quadrant

$30 per quadrant

7311

Alveoloectomy with extractions (1-3 teeth)

$38

$30

$20

$10

7321

Alveoloectomy without extraction (1-3 tooth spaces)

$38

$30

$20

$15

7250

Surgical removal of residual tooth roots

$75

$60

$40

$30

7285/7286/ 7287

Biopsy of oral tissue

$60

$40

$20

$10

Brush biopsy (cell sample collection)

$30

$20

$10

$5

7288

Emergency 9110 (9430)

Emergency oral exam including palliative treatment (if treatment includes a listed procedure, regular copayment also applies) during regular dental center office hours

$20

$20

$20

$20

9110 (9440)

After office hours

$40

$40

$40

$40

$20

$20

$20

$20

Other 9999

Failed appointment (without 24-hour notice)

Orthodontics 8070/8080 8090

Orthodontic treatment to correct malocclusion, limited to one continuous two-year course of treatment per eligible child through age 18**

$2,350

$1,800

$1,400

$1,200

8090

Orthodontic treatment to correct malocclusion, limited to one continuous two-year course of treatment per eligible member age 19 years or older**

$2,650

$2,650

$1,700

$1,500

8680

Retainers

$125 per retainer

$125 per retainer

$75 per retainer

$50 per retainer

8660

Orthodontic initial consultation

No charge

No charge

No charge

No charge

* Precious metals, if used, will be charged to the member at the dentist’s cost. ** Note: In order to be covered, orthodontic treatment: 1) must be received in one continuous course of treatment; 2) must be received in consecutive months and 3) must not exceed 24 consecutive months. 8 

Dental PPO and HMO Producer Brochure

Dental PPO and dental HMO provider networks

DEL NORTE

Dental HMO and PPO providers

SISKIYOU

MODOC

Dental PPO providers only Access to non-network dental providers only SHASTA HUMBOLDT

LASSEN

TRINITY

TEHAMA

MENDOCINO

PLUMAS BUTTE

GLENN

SIERRA NEVADA

YUBA

YOLO NAPA

PLACER

EL DORADO SACRAMENTO

ALPINE AMADOR OR AMAD

RA

S

SONOMA

SUTTER

LAKE COLUSA

LA A

TUOLUMNE

C

SAN CONTRA- JOAQUIN COSTA

VE

SOLANO

MARIN

MONO

SAN FRANCISCO ALAMEDA SAN MATEO

SANTA CLARA

MARIPOSA

STANISLAUS MERCED

MADERA

SANTA CRUZ

SAN BENITO

FRESNO

INYO

TULARE MONTEREY

KINGS

SAN LUIS OBISPO

KERN SAN BERNARDINO

SANTA BARBARA VENTURA

LOS ANGELES

ORANGE

RIVERSIDE

SAN DIEGO IMPERIAL

Find the nearest dental providers online at blueshieldca.com. For more information, call your Blue Shield sales representative or (888) 800-2742 for ancillary group products. We’re ready to help.

Dental PPO and HMO Producer Brochure

9

Footnotes 1 A  ccording to a 2004 survey conducted by the Life Insurance and Market Research Association (LIMRA International, Inc.), 56% of employees indicated dental was their most desired benefit. 2 Dental providers outside California are contracted through Dental Benefits Providers, Inc. Dental providers in California are contracted through Dental Benefit Providers of California. 3 S mile Basic Voluntary 75/1000/No Ortho/MAC has a 12-month waiting period for major services. Major services for Smile Basic Voluntary 75/1000/No Ortho/MAC are defined as major services listed for Smile Basic 75/1000/No Ortho/MAC plus oral surgery, endodontics, and periodontics. 4 F or Blue Shield of California’s Smile Plus Gold 50/1500/Ortho/U85 and Smile Deluxe Gold 50/1500/Ortho/U85 Plan, the dental plan administrator uses a different schedule of allowable amounts for non-network dentists than that used for network dentists. If you go to a non-network dentist, your reimbursement for a service by that non-network dentist may be less than the amount billed. 5 T he coinsurance percentage indicated is a percentage of allowed amounts that Blue Shield pays to providers. Non-network providers can charge more than Blue Shield’s allowable amount. When members use non-network providers, they must pay the applicable copayment/coinsurance plus any amount that exceeds Blue Shield’s allowable amount. Charges in excess of the allowable amount don’t count toward the calendar-year deductible or copayment maximum. 6 Not subject to plan deductibles with network or non-network dentists. 7 O  ne additional routine adult prophylaxis (including periodontal prophylaxis for gingivitis) for women during pregnancy and one periodontal maintenance visit if warranted by a history of periodontal treatment and one course (up to four quadrants) of periodontal scaling and root planing for women during pregnancy with a documented existing periodontal condition. Note: This document is only a summary for informational purposes. It is not a contract. Please refer to the Evidence of Coverage and the Group Health Service Agreement for the exact terms and conditions of coverage available through a Blue Shield sales representative. All Blue Shield dental plans are underwritten by Blue Shield of California and are subject to limitations and exclusions which can be found on the dental plan benefit summaries at blueshieldca.com on Producer Connection. Printed copies are available by ordering copies online or by calling Producer Services at (800) 559-5905.

10 

Dental PPO and HMO Producer Brochure

blueshieldca.com

An Independent Member of the Blue Shield Association

A19779 (5/08)