2020 Blue Cross and Blue Shield Service Benefit Plan - FEP Blue Focus
Section 5(g). Dental Benefits
Page 103


Note: The calendar year deductible applies to almost all benefits in this Section. We say “(No deductible)” when it does not apply.
 
Important things you should keep in mind about these benefits:
 
  • Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.
     
  • If you are enrolled in a Federal Employees Dental/Vision Insurance Program (FEDVIP) Dental Plan, your FEHB Plan will be the primary payor for any covered services and your FEDVIP Plan will be secondary to your FEHB Plan. See Section 9, Coordinating Benefits with Medicare and Other Coverage, for additional information.
     
  • Be sure to read Section 4, Your Costs for Covered Services, for valuable information about how cost-sharing works. Also, read Section 9 for information about how we pay if you have other coverage, or if you are age 65 or over.
     
  • The calendar year deductible of $500 per person ($1,000 per Self Plus One or Self and Family enrollment) applies to the accidental injury benefit below.
     
  • You must use Preferred providers in order to receive accidental dental injury benefits for treatment after 72 hours of the accident. Covered services provided more than 72 hours after an accident are subject to the deductible and coinsurance.
 
Benefit Description

Accidental Injury Benefit


We provide benefits for services, supplies, or appliances for dental care necessary to promptly repair injury to sound natural teeth required as a result of, and directly related to, an accidental injury. To determine benefit coverage, we may require documentation of the condition of your teeth before the accidental injury, documentation of the injury from your provider(s), and a treatment plan for your dental care. We may request updated treatment plans as your treatment progresses.

Notes:

 
  • An accidental injury is an injury caused by an external force or element such as a blow or fall and that requires immediate attention. Injuries to the teeth while eating are not considered accidental injuries.
     
  • A sound natural tooth is a tooth that is whole or properly restored (restoration with amalgams or resin-based composite fillings only); is without impairment, periodontal, or other conditions; and is not in need of the treatment provided for any reason other than an accidental injury. For purposes of this Plan, a tooth previously restored with a crown, inlay, onlay, or porcelain restoration, or treated by endodontics, is not considered a sound natural tooth.
     
  • We provide benefits for accidental dental injury care in cases of medical emergency when performed by Preferred or Non-preferred providers. See Section 5(d) for the criteria we use to determine if emergency care is required. You are responsible for the applicable cost-share as shown here. If you use a Non-preferred provider, you may also be responsible for any difference between our allowance and the billed amount.
     
  • All follow-up care must be performed and billed for by Preferred providers to be eligible for benefits.

You Pay
Treatment of an accidental dental injury within 72 hours:

Preferred: Nothing (no deductible)

Non-preferred professional providers (Participating and Non-participating):

 
  • Participating: Nothing (no deductible)
     
  • Non-participating: Any difference between our allowance and the billed amount (no deductible)

Treatment after the initial 72 hours:

Preferred: 30% of the Plan allowance

Non-preferred (Participating/Non-participating): You pay all charges