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Below explanation is for California plan only

Blue Shield Dental logo  Blue Shield Dental Insurance 
(877)566-5454 Toll Free

Stand-alone Dental Plans for ALL AGES

BLUE SHIELD DENTAL PLANS MONTHLY RATES (all ages) effective 3/01/2013
Blue Shield dental & vision plans
Specialty Duo
Dental & Vision
Package * ¹ ²
Dental PPO ¹ ²
Dental HMO ²
PREMIUMS PER MONTH
Member Pays
Member Pays
Member Pays 8
Adult or Child $54.10 $41.40 $19.80
Adult & Spouse/domestic partner $112.20 $83.90 $39.30
Adult & Child $82.10 $62.70 $34.80
Adult & Children $122.00 $93.40 $40.60
Family $190.20 $145.60 $76.50
Calendar-year deductible per person $50 $50 $0
Calendar-year maximum per person $1000 $1000 Not limited
SIDE-BY-SIDE COMPARISON OF THE PLANS
WAITING PERIODS
Diagnostic & preventive services 0 months 0 months 0 months
Basic Services 3 months 3 months 0 months
Major Services 12 months 12 months 0 months
Orthodontics 12 months 12 months 12 months
Benefits - using in-network dentists 5
DIAGNOSTIC & PREVENTIVE CARE
Annual exam & six-month checkups $0 $0 $0
Cleanings $0 $0 $0
X-rays $0 $0 $0
BASIC SERVICES
General Anesthesia $23 $23 $190
IV Sedation $98 $98 $200
Composite filling 1 surface (resin) $37 $37 $18
Composite filling 2 surfaces (resin) $56 $56 $23
Anterior root canal $156 $156 Covered under
major services
Molar root canal $234 $234
Single tooth extraction $40 $40
Periodontal root planing per quadrant $65 $65
MAJOR SERVICES
Anterior root canal Covered under
basic services
$155
Molar root canal $290
Single tooth extraction $34
Periodontal root planing per quadrant $75
Crown (porcelain fused to noble metal) $320 $320 $300
Osseous surgery per quadrant $263 $263 $303
Removal of impacted tooth (complete bony) $113 $113 $125
Bridge retainer/unit $313 $313 $300
Bridge Pontic/false tooth/unit $293 $293 $300
Complete denture - upper or lower $388 $388 $400
ORTHODONTICS
Adult $2,650 $2,650 $2,650
Child $2,350 $2,350 $2,350

* Specialty Duo package includes a comprehensive vision plan. Plan includes $0 eye exam copayment, $25 lense and low-vision aids copayment, and a $100 frame allowance.
¹ Diagnostic and preventive services are not subject to plan deductibles.
² Enrollee must be a California resident at the time of enrollment. Benefits are only available within the state of California except in emergency situations. If enrollee had a Blue Shield IFP dental plan cancelled, enrollee must wait 6 months from the date of cancellation before reapplication.
5. When member used dentists who are not in the network, Blue Shield reimburses up to the amount listed, and member is responsible for all charges in excess of the amount Blue Shield pays in addition to member's calendar-year deductible.
8. All services must be performed, prescribed or authorized by member's dentist, chosen from the Blue Shield Dental HMO Dental Provider Directory. If member needs to see a specialist, member must get a referral from member's dental provider to receive covered services.
Note: Smile PPO & Value Smile PPO plans are no longer available effective 11/01/2011.

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APPLY ONLINE Application - Blue Shield of California Dental Application
OR

PRINT & MAIL Application - Blue Shield of California Dental Application

Download Blue Shield Easy$Pay Enrollment Form

Download Blue Shield Dental Plans at a Glance

Download Specialty Duo package brochure

Blue Shield of California Dentist Database

Dental PPO Plan Benefits
  • Access to over 21,000 general care and specialty dentists in California
  • A wide range of dental benefits, including most diagnostic and preventive services and oral cancer screening, at no additional cost when using a dental network provider
  • Coverage even when your clients use a non-network dentist. The plan reimburses members up to an allowed amount for covered services and members pay the remaining balance of the total billed charges
  • No waiting period for diagnostic or preventive services (3-month waiting period for minor services; 12-month waiting period for major restorative and orthodontic services)
  • Affordable copayments for basic and major services
  • Orthodontic benefits are available for both children and adults
  • $50 deductible per member, per calendar year
  • $1,000 per member per calendar-year benefit maximum, of which up to $500 per member per year can be used for non-network benefits
The Specialty Duo Dental + Vision Package
Specialty Duo dental plan benefits:
  • Specialty Duo dental plan offers the same benefits as the Dental PPO plan above
Specialty Duo vision plan benefits:
  • Access to more than 5,900 vision care providers in California including retail chains open on evenings and weekends.
  • Choice of network or non-network vision providers
  • $0 copayment for eye exams
  • $25 copayment for lenses and low-vision-aids
  • $100 frame allowance that can be used towards any pair of frames
  • Coverage for an eye exam once every 12 months
  • Coverage for lenses or contact lenses every 24 months, or 12 months with a prescription change
  • Coverage for frames every 24 months
  • 90-day waiting period for services
  • Benefit for non-prescription sunglasses for members who have had LASIK or PRK surgery
Dental HMO Plan Benefits
  • Access over 9,000 dental provider locations in California
  • A wide range of dental benefits, including most diagnostic and preventive services at no additional cost
  • No deductibles and no calendar-year maximums
  • No waiting periods except for a 12-month waiting period for orthodontic services
  • Affordable fixed copayments for basic and major services
  • Orthodontic benefits are available for both children and adults  
  • Specialty care available with a referral from a primary dentist
  • Virtually no claim forms
Or you can fill in this form to have your Blue Shield Dental Insurance brochure with pricing & application mailed to you. Further information on our plans is shown below. Or just call us Toll-free at 877-Look4Life (877-566-5454).
Blue Shield Dental Insurance Coverage Requested
Our Ages
(under age 65)
  My Age or DOB       Spouse's Age  
People Covered
Dental Plan Choice

Customer Information
Full Name
E-mail
Street Address
City
County
State
Zip Code
Home Phone
Work Phone
FAX

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Dental HMO (Dental Health Maintenance Organization) plans also referred to as pre-paid plans, require you to choose one dentist or dental facility to coordinate all of your oral health needs. If you need to see a specialist, your primary care dentist will refer you; specialty care may require preauthorization. A typical DHMO-type plan doesn't have any deductibles or maximums. Instead, when you receive a dental service, you pay a fixed dollar amount for the treatment (a "copayment"). Often, diagnostic and preventive services have no copayment, so you pay nothing for these services. However, generally if you visit a dentist outside of the network, you may be responsible for the entire bill. Typically, the least expensive of dental plans.

Dental PPO (Dental Preferred Provider Organization) plans offer a network feature and usually offer a balance between lower costs and dentist choice. PPO dentists participate in the network thereby agreeing to accept contracted fees as payment in full rather than their usual fee for patients with the PPO. When you visit a PPO dentist, you typically pay a certain percentage of the reduced rate (called coinsurance) and the plan pays the rest. The percentage usually varies by the type of coverage such as diagnostic and preventive, major services. While you typically have the lowest out-of-pocket costs if you visit a PPO dentist, the plan allow you to visit the dentist of your choice, even if they are not in the network. Typically, the most expensive of dental plans.

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