How The Plan
Works
Who Is Eligible
What Are The Plan Benefits
How Much Does The Plan Cost
What Benefits Are Excluded
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Dental Provider Directory |
| BC Life & Health Insurance Company
has Created the Prudent Buyer Dental Plan, a Preferred Provider
Organization dental plan, to keep your teeth healthy and your smile
bright. The hundreds of dedicated professionals who comprise the Prudent
Buyer Services including routine check-ups, cleanings, fillings, crowns
and dental surgery. |
The Prudent Buyer Dental Plan was
designed with two goals in mind. The first and foremost is to promote good
dental hygiene and preventive care, recognized as important elements is
total health care package. The second goal is to provide you with the
dental care you need in a convenient, cost-conscious manner, thus
providing many dental services at reduced or no out-of-pocket cost.
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The Plan features Preventive and
Diagnostic Care at little or no cost, low cost Basic Care, and a benefit
schedule that can help you offset the high cost of Major Care dental
work. Please read the following information for details on how the
plan works, specific benefit information and certain exclusions and
limitations that apply.
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| How the Prudent Dental
Plan Works |
The Prudent Buyer Dental Plan
Network is made up of a large number of dentists in California who have
agreed to provide services at negotiated rates to Prudent Buyer Plan
Members. When you Choose a Participating Plan Dentist, you pay nothing for
Preventive and Diagnostic Care, Such as regular check-up, cleanings and
X-rays. Other benefits are provided for specified basic and major dental
care.
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The Plan lets you know up front in
flat dollar amounts how much the plan pays for the covered services. This
means that you are able to calculate easily how much you will have to pay
once you have determined your dentist's fee for the specific procedures
listed.
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It is your benefit to use a Participating
Plan dentist because Blue Cross of California and BC Life & Health
Insurance Company have negotiated the amounts that Prudent Buyer Plan
members are charged for services. You may choose a non-Participating
dentist, and the Plan still provides benefits, but your out-of-pocket
expense may be greater as the negotiated fees do not apply to non-
Participating providers. You are responsible for any charges in excess of
the stated benefit.
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The Participating Plan Network is
large, and your current dentist already may be part on the Network. So be
sure to check the Prudent Buyer Plan Dental directory before you choose a
dentist. It could save you money.
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Calendar Year Deductible is
he amount of out-of-pocket expense for which you are responsible before
your benefits are available. The Calendar Year Deductible is $50 per
person, with a maximum of 3 calendar year deductibles per family (total
$150). The deductible is waived for the Preventive and Diagnostic Care
only at Participating Plan dentists.
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Calendar Year Maximum
Benefit: All dental benefits are limited to a maximum payment by BC
Life & Health of $1,000 for expenses incurred by each enrolled member
during a calendar year.
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Waiting Periods: There is no
waiting period for Preventive and Diagnostic Care. Coverage for Basic Care
begins after three continuous months and for Major Care after twelve
continuous months of coverage.
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| Customer Service: BC Life
& Health Insurance Company's professional Dedicated Enrollment Units
are available to answer any questions you may have about your Policy, and
to assist you in your customer service needs. The toll-free number is
listed on your Prudent Buyer Dental Plan identification card that you will
receive once your enrollment is approved. |
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| Benefit
Schedules |
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| Coverage is provided only for
the
services services below. |
| To use the following schedules,
first determine your dentist's fee, then look up how much the plan pays.
Then you can calculate easily how much you will have to pay for the
specific services after your deductible has been met (where applicable.
The dollar amounts are maximums. The Plan pays either the specified
amount, or the actual amount charged by your dentist, whichever is lower.
You are responsible for any charges in excess of the stated benefit. |
|
| Preventive & Diagnostic
Care |
| Coverage begins upon approval of
your application. You are limited to two oral examinations and two
dental cleanings per member, per year. The calendar year deductible is
waived for these services only when rendered by a Participating
Plan dentist. |
|
At a
Participating dentist |
At a Non-Participating
dentist |
|
The Plan Pays |
The Plan Pays |
| Procedure |
|
|
| Initial Oral exam |
100% |
$25 |
Periodic Oral Exam
Limited to 2 per member per year |
100%
|
$18
|
| Emergency Oral Exam |
100% |
$28 |
| Bitewing X-rays - single film |
100% |
$16 |
| Bitewing X-rays - two film |
100% |
$18 |
Single (periapical) X-rays - first film
Single X-rays - additional films |
100%
100% |
$13
$8 |
| Bitewing X-rays - four films |
100% |
$26 |
Full mouth X-rays
limited to one set every 3 years |
100%
|
$60
|
Routine cleaning
limited to 2 per adult per year |
100%
|
$39
|
Routine cleaning
limited to 2 per child per year |
100%
|
$30
|
Cleaning with fluoride
limited to 2 per child per year |
100%
|
$35
|
Tropical fluoride only
limited to 2 per child per year |
100%
|
$14
|
| * Total benefit for single and
bitewing X-rays not to exceed cost of full mouth-$60 an non-Participating
dentists |
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| Basic & Major Dental Care |
| After the calendar year deductible
has been satisfied, benefits are paid according to the following
schedules. Although the schedule is the same for both Participating and
non-Participating providers, you may experience greater out-of-pocket
expense at a non-Participating provider. |
|
| Basic Dental Care |
| Coverage begins after the policy
has been in effect for three continuous months. |
|
| Procedure |
Plan Pays |
| Filling - one surface, primary |
$ 38 |
| Filling - one surface, permanent |
$ 42 |
| Filling - two surface, primary |
$ 49 |
| Filling - two surface, permanent |
$ 55 |
| Filling - three surface, primary |
$ 60 |
| Filling - three surface, permanent |
$ 72 |
| Filling - four or more surface,
primary |
$ 70 |
| Filling - four or more surface,
permanent |
$ 84 |
| Extraction - single tooth (simple) |
$ 49 |
| Extraction - each additional tooth
(simple) |
$ 46 |
| Surgical extraction |
$ 84 |
| Removal of impacted tooth - soft
tissue |
$ 111 |
| Removal of impacted tooth - partial
bony |
$ 148 |
| Removal of impacted tooth - complete
bony |
$ 180 |
|
|
| Note: |
| Adult- Any person or dependent 19
years or older covered by this Policy. |
| Child- Any person or dependent 18
years or younger covered by this Policy. |
|
| Major Dental Care |
| Coverage begins after the policy
has been in effect for twelve continuous months. |
|
| Procedure |
Plan Pays |
| Scaling/root planing per quadrant |
$48 |
| Gingivectomy - per tooth |
$40 |
| Gingivectomy - per quadrant |
$145 |
Osseous surgery per quadrant
paid at $70 per tooth to a maximum of $277/quadrant |
$277 |
| Root Canal - 1 canal |
$154 |
| Root Canal - 2 canal |
$189 |
| Root Canal - 3 canal |
$242 |
| Inlay - one surface |
$172 |
| Inlay - two surface |
$198 |
| Inlay - three surface |
$220 |
| Onlay - in addition to inlay |
$57 |
| Crown (except stainless steel) |
$264 |
| Stainless steel crown |
$57 |
| Pontic |
$264 |
| Post & core - in addition to
crown |
$75 |
| Complete denture (upper or lower) |
$343 |
| Partial denture (upper or lower) |
$308 |
| Denture reline (Chairside) |
$75 |
| Denture reline (lab) |
$106 |
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|
| Eligibility & Enrollment |
|
| Who is eligible for coverage? |
- You, the principal insured, if under age 64
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- Your spouse in under age 64
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- You or your enrolled spouse's unmarried children under 19 years of
age
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- You or your enrolled spouse's unmarried children between the ages of
19 through 22 who are defined as
dependent by IRS regulations
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- Any un married children of you or your enrolled spouse between the
ages of 19 through 22 who continue to be dependent upon you for at
least half of their support
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|
| Date Coverage Begins |
| The effective date of your Prudent
Buyer Dental Plan is assigned by BC Life & Health Insurance Company
and will be the first of the month after approval. |
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| Premium Rates
For Orange County |
| The rates listed are monthly rates.
Monthly payment is available only in tandem with Monthly Checking Account
Deduction billing. If you wish to pay Bi-monthly, Multiply by two; if you
prefer to pay quarterly, multiply by three. |
|
Contract Type
|
Age Band |
Monthly Premiums |
| Subscriber
Only |
19-64 |
$38 |
| Subscriber
& Spouse |
19-64 |
$74 |
| Subscriber
& Child |
19-64 |
$59 |
| Subscriber
& Children |
19-64
|
$92 |
| Family |
19-64 |
$118 |
| 1 Child |
0-18 |
$31 |
| 2
Children |
0-18 |
$59 |
| 3+Children |
0-18 |
$84 |
|
To Apply Now (Click Here) |
| Call
Our Office For Rates In Other Counties.
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Coverage ceases under the Prudent Buyer PPO Dental Plan
when: You do not pay the
premium when due, subject to the grace period; upon the first of the month
in which any covered member attains age 65; any member becomes eligible
for Medicare coverage even if no application for Medicare coverage is
made; any members eligible for Medicare coverage even if no application
for Medicare coverage is made; the spouse is no longer married to the
principal insured; the child fails to meet previously listed eligibility
requirements; any member becomes enrolled in any other Blue Cross
non-group coverage; any covered member resides in a foreign country for
more than six consecutive months or is absent from California for more
than six consecutive months. You must notify BC Life & Health Insurance of all changes
affecting any member’s eligibility.
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| Non-Duplication of Blue Cross Benefits |
If, while covered under this Policy, the member
is covered by another Blue Cross of California/BC life & Health
Individual policy, he or she will be entitled only to the benefits of the
policy with greater benefits. The
Blue Cross Companies will refund any premium received under the policy
with the lesser benefits, covering the time both policies were in effect. However,
any claims payments made by the Blue Cross Companies under the policy with
the lesser benefits will be deducted from any such refund of premium.
|
| Arbitration |
Any dispute between
you and Blue Cross of California and/or its affiliates must be resolved by
binding arbitration if the amount in dispute exceeds the jurisdictional
limits of the Small Claims Court. Any
such dispute will be resolved not by law or resort to court process,
except as California law provides for judicial review of arbitration
proceedings. Under this
coverage, both you and Blue Cross of California and its affiliates are
giving up the right to have any dispute decided in a court of law before a
jury.
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| Exclusions and Limitations |
We will not furnish benefits for:
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Unlisted Services:
Services not specifically listed in this Policy.
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Excess Amounts: Any
amounts in excess of the maximum amounts stated in the “Benefit
Schedule” section.
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Expense Before Coverage Begins: Services received before your Effective Date or during an
inpatient stay that began before your effective Date.
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| End of Coverage Begins: Services received after your coverage ends.
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Services For Which You
Are Not Legally Obligated To Pay: Services for which no charge is made to you in the
absence of insurance coverage.
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Worker’s
Compensation: Any condition for which benefits are recovered or can
be recovered, either by adjudication, settlement or otherwise, under any
workers’ compensation, employer’s liability law or occupational
disease law, even if you do not claim those benefits.
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War: Disease
contracted or injuries sustained as a result of war declared or
undeclared, conditions caused by the inadvertent release of nuclear energy
when government funds are available for treatment of illness or injury
arising from such release of nuclear energy.
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Government Services: Any services provided by a local, state, county or federal
government agency including any foreign government.
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Services from Relatives:
Professional services received from a person who lives in the
Insured’s home or who is related to the Insured by blood, marriage or
adoption.
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Cosmetic Dentistry:
Any services performed for cosmetic purposes are not covered under
this Policy, unless they are for correction of functional disorders or as
a result of an accidental injury occurring while you were covered under
this Policy.
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Charges for treatment by other than a licensed dentist or
physician, except charges for dental prophylaxis performed by a licensed
dental hygienist, under the supervision and direction of a dentist.
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Replacement of an
existing prosthesis which has been lost or
stolen; or which in the opinion of the dentist is or can be made
satisfactory.
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Replacement of a fixed
or removable prosthesis for
which benefits were paid by BC Life & Health, if such replacement
occurs with in five years of the original placement, unless the denture is
a stayplate used during the healing period for recently extracted anterior
teeth.
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Orthodontic services, braces, appliances and all
related services.
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Diagnosis or Treatment of the Joint of the Jaw and/or
Occlusion (the way upper and lower teeth meet)
services, supplies or appliances provided in connection with:
- Any
treatment to alter, correct, fix, improve, remove, replace,
reposition, restore or otherwise treat the joint of the jaw (temporomandibular
joint) or associated musculature, nerves and other tissues for any
reason or by any means; or
- Any
treatment, including crown, caps and/or bridges to change the way the
upper and lower teeth meet (occlusion0; or
- Treatment
to change vertical dimension (the space between the upper and lower
jaw) for any reason. Or by any means including the restoration of
vertical dimension because teeth have worn down.
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Correction of congenital or developmental malformation
for a Principal Insured or Dependent Insured including but not limited to
cleft palate, maxillary or mandibular (upper and lower jaw) malformations,
enamel hypoplasia (lack of development), fluorosis a type of discoloration
of the teeth), and anodontia (congenitally missing teeth).
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Adjustment, repairs or relines to prostheses
for a period of six months from initial placement if the prostheses were
paid for under this Policy.
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Fixed bridges, removable cast partials and/or
cast crowns with or without veneers and inlays for patients under sixteen
years of age.
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Replacement of crowns and cast
restorations including porcelain
inlays and porcelain crowns for which benefits were paid by BC Life &
Health, if such replacement occurs within five years of the original
placement.
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Transfer of care:
If a Principal Insured transfers
from the care of one dentist to that of another dentist during the course
of treatment, or if more than one dentist renders services for one dental
procedure, BC Life & Health shall be liable only for the amount it
would have been liable for had one dentist rendered the services.
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Prescribed drugs, pre-medication or analgesia. Malignancies
and Neoplasms: Services for treatment of
malignancies and neoplasms are not covered Dental Benefits.
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All hospital costs and any additional fees
charged by the dentist for hospital treatment. Services or Supplies That
Are Not Medically Necessary. |
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| Replacement of teeth missing
prior to the effective date of coverage with partial dentures, complete
dentures, or fixed bridges.
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| How to enroll |
| If you are a new member and want
dental ONLY: |
| ·
Compete and sign the
attached application |
| ·
Determine your premium (see
page 7) and your payment plan (see below) |
| ·
Write a check payable to Blue Cross of California |
| ·
Send the application and
payment to Blue Cross or your agent |
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For those applying for Blue Cross medical coverage
and dental coverage:
- See instructions in the Individual Enrollment
Application
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For Blue Cross members who want to ADD dental:
·
Complete the attached
application
·
Determine your premium (see
page 7) – It should be the same type of billing as you medical coverage.
Even if you are on Monthly Checking Account Deduction, you
must send the first month’s premium
with the application.
·
Write a check payable to
Blue Cross of California
Send the application to:
(see
address below) |
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To determine your initial premium*:
·
If you want to pay your bill monthly, fill out the attached
account deduction form and submit it along with a check for one month’s
premium and a blanc check marked “VOID”
·
If you want to pay your bill every other month, write a
check for two months’ premium
·
If you want to pay your bill every three months, write a
check for three months’ premium
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| Download
& Print Application |
 |
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Send your
application and payment to:
Other
Options For Contacting Us:
Telephone
Toll Free - 800.539.8490
Fax - 949.852.0544
E-Mail - info@affordablegrouphealth.com
Affordable Group Health.com
Benefit Specialist Insurance Services
8 Corporate Park, Suite 130
Irvine, Ca 92606
License
# 0577258
When your enrollment is approved you will receive a
Prudent Buyer Plan Dental Policy. Please
review it carefully, as it contains specific details about your benefits,
coverage, exclusions and limitations.
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| *
If you are a Blue Cross member you
must select the same payment plan as your health plan.
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