Dental HMO and PPO
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Optional Supplemental Dental HMO and PPO Plans

Having good oral health is important to your overall health. Studies have linked gum disease to increased risks of heart disease, stroke and diabetes.

Nearly 25% of people ages 65 to 75 have gum disease. Regular dental exams can play a vital role in the early detection of many health problems.

Our optional supplemental dental HMO plan has a lower premium than our PPO plan, with a monthly premium of $13.20 and offers fixed member out-of-pocket costs. Our HMO plan gives you access to more than 24,000* general dentists statewide.

Our optional supplemental dental PPO plan lets you choose from a larger list of dentists, but you pay a higher premium for this choice – $34.90 for the monthly plan premium. Our PPO plan gives you access to nearly 44,000* general dentists and specialists statewide.

Optional supplemental dental HMO or PPO plan vs no coverage: potential savings if seeing a network dentist.

Description
Patients without coverage
(Standard list price for
two preventive visits)
Optional supplemental
dental HMO plan
member estimated
out-of-pocket costs
Optional supplemental
dental PPO plan
member estimated
out-of-pocket costs
Annual Premium
$0.00
$158.40
($13.20 x 12 months)
$418.80
($34.90 x 12 months)
Annual dental exam,
teeth cleaning, and X-rays
$443.00
(D0120, D1110, D0210)
$5.00
$0.00 (0%)
Annual deductible
$0.00
$0.00
$50.00
6-month follow up
and cleaning
$1,500.00
(D3330)
$5.00
$0.00 (0%)
Molar root canal
$0.00
$335.00
$750.00 (50%)
Noble metal
porcelain crown
$1,500.00
(D2750)
$275.00#
$0.00 (0%)
Total cost
$3,747.00
$778.40
$1,968.80
Potential one-year savings
$2,968.60
$1,778.20

* Dental providers in California are available through a contracted dental plan administrator. Network numbers are as of August 2017. The optional supplemental dental HMO plan is not available in San Luis Obispo and Santa Barbara counties.

The sample costs are based on the Fair Health 90th percentile amounts for the 900 ZIP code (as of August 2017). These costs may not apply to you.

This amount is your copayment if a general dentist performs the molar root canal. Your copayment will be higher if the molar root canal is performed by a specialist.

# You pay the copayment plus the cost of precious or semi-precious metals.

Optional supplemental dental HMO plan highlights

  • A wide range of dental benefits, including many diagnostic and preventive services at no charge to you
  • Fixed copayments for basic and major services
  • No waiting period for most services
  • No deductibles
  • Specialty care available with a referral from your dental provider
  • Virtually no claim forms

Optional supplemental dental PPO plan highlights

  • Unlike the HMO plan, you have access to out-of-network dentists and specialists
  • Specialist care available with NO referral needed from your dentist
  • A wide range of dental benefits, including 100% coverage for in-network diagnostic and preventive services
  • No claim forms if you go to an in-network dentist
  • Six-month waiting period for major services only

Optional supplemental dental HMO and PPO plan benefits at a glance
(Optional dental HMO/PPO benefits comparison)

Benefit
With the optional supplemental
dental HMO plan, you pay*:
With the optional supplemental
dental PPO plan, you pay:
Diagnostic and preventive services -
For your annual dental exam and
six-month checkup.
No deductible
No deductible
• Comprehensive oral exams (D0150)
• Periodic oral exams (D0120)
• Complete X-rays (D0210)
• Adult prophylaxis
(cleanings, every 6 months) (D1110)
$5
$0
$0
$5
 
You pay nothing if you go in-network 
and 20% if you go out-of-network
Minor restorative services 
- Keep your teeth healthy.
No waiting period;
No deductible
No waiting period;
$50 deductible per person
• One-surface composite resin
restoration – anterior (D2330)
• Two-surface composite
resin restoration – anterior (D2331)
$11
 
$17
 
20% if you go in-network and
30% if you go out-of-network
Annual deductible
None
$50 per person not applied to 
diagnostic and preventive services
Annual benefit limit
For specialist services only: $1,000
$1,500 ($1,000 may be used for
services provided by out-of-network
dentists and specialists)


This chart is only a summary. For a complete list of the benefits, exclusions, and limitations, please refer to the Evidence of Coverage.

* All services must be performed, prescribed, or authorized by your network dentist. For the optional supplemental dental HMO only ― If you need to see a specialist, you must get a referral from your dental provider to receive covered specialist services.

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July 25, 2018
2:00PM
Blue Shield Medicare Advantage, Medicare Supplement,
and PDP seminar
The Redwoods Retirement Community
352 Miller Avenue
Recreation Hall
Mill Valley, CA
Call to RSVP (888) 521-2171

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