Optional Supplemental Dental HMO and PPO plan
Something to smile about
Blue Shield offers two optional supplemental dental plans to Blue Shield of California Medicare Advantage Prescription Drug Plan members, depending on the county where your client resides. Members can choose between an optional supplemental Dental HMO or Optional Supplemental Dental PPO1. These supplemental plans offer a wide range of dental benefits, including many diagnostic and preventive services at no charge to your client.
HMO Plan Effective January 1, 2025
- $16.00 additional monthly plan premium
- Access to a large network of dentists that includes 1,000 additional dentists including specialists compared to the dental discount benefit that most of your clients have embedded in their Blue Shield MA-PD plan; they must choose a participating dentist
- 48 additional covered services and lower average copays, compared to the dental discount benefit that most of your clients have embedded in their Blue Shield MA-PD plan
- No deductibles
- No waiting periods
PPO plan Effective January 1, 2025
- $47.00 additional monthly plan premium
- See any dentist; your client will generally be charged less for services if they use a participating dentist
- Access to 10,000 additional dentists including specialists, compared to the dental discount that most of your clients have embedded in their Blue Shield MA-PD plan
- 38 additional covered services including implants, compared to the dental discount benefit that most of your clients have embedded in their Blue Shield MA-PD plan
- $50 calendar-year deductible for services beyond diagnostic and preventive services
- No waiting period
No waiting period – enroll today!
Your clients can sign up for dental coverage by filling out the optional supplemental dental HMO or PPO plan enrollment form and sending it to us at the fax number or address on the enrollment form. They can enroll for the first time in either plan when they enroll in a Blue Shield Medicare Advantage plan, or anytime thereafter!
If your clients have questions about how this coverage may compare to coverage they already have, they should call Customer Service at (800) 776-4466, (TTY 711), 8 a.m. to 8 p.m., seven days a week.
It’s easy to find a dentist or see if your client's current dentist is in our network. Visit blueshieldca.com/FAD, choose the Dentists icon, and when asked if you have a plan in mind, select the applicable Blue Shield 65 Plus Optional Dental Plan Network (HMO or PPO).
Please note the Optional Supplemental Dental HMO plan is not available to Blue Shield AdvantageOptimum Plan (HMO), Blue Shield AdvantageOptimum Plan 1 (HMO), Blue Shield Inspire (HMO D-SNP), Blue Shield Select (PPO), and Blue Shield TotalDual Plan (HMO D-SNP) members, and Blue Shield 65 Plus (HMO) members in San Luis Obispo and Santa Barbara counties.
The Optional Supplemental Dental PPO plan is not available to Blue Shield AdvantageOptimum Plan, Blue Shield AdvantageOptimum Plan 1, Blue Shield TotalDual Plan (HMO D-SNP), and Blue Shield Inspire (HMO D-SNP) members.
Optional Supplemental Dental HMO vs Optional Supplemental Dental PPO
| Optional Supplemental Dental HMO | Optional Supplemental Dental PPO | ||
|---|---|---|---|
| Monthly Optional Supplemental Dental plan premium |
$16 | $47 | |
| Calendar-year deductible (not applicable to diagnostic and preventive services) | None | $50 | |
| Calendar-year maximum2 | None |
$1,500 for covered preventive and comprehensive dental services combined, whether the services are performed by a participating general dentist or a dental specialist. You pay any amount above the $1,500 calendar-year benefit maximum. $1,000 for covered preventive and comprehensive dental services performed by non-participating dentists in a calendar year. You pay any amount above the $1,000 calendar-year benefit maximum. |
|
| Network access | Participating dentists only | Participating dentists | Non-participating dentists |
| Waiting period | No waiting period | No waiting period | No waiting period |
| Summary list of services covered (ADA code)3 | You pay | You pay | You pay |
| Diagnostic services | |||
| Comprehensive oral evaluation (D0150) | $5 copay (no frequency limit) | 0% (1 visit every 6 months) | 20% (1 visit every 6 months) |
| Complete X-rays – (D0210) | $0 copay (1 series every 24 months) | 0% (1 series every 24 months) | 20% (1 series every 24 months) |
| Preventive care | |||
| Prophylaxis – adult (D1110) | $5 copay (1 every 6 months) | 0% (1 cleaning every 6 months) | 20% (1 cleaning every 6 months) |
| Restorative services | |||
| One surface composite resin restoration – anterior (D2330) | $11 copay (no frequency limit) | 20% (no frequency limit) | 30% (no frequency limit) |
| Crown (porcelain fused to noble metal) (D2750) | $275 copay (1 per plan year, exact tooth, every 5 years) | 50% (1 every 5 years, exact tooth) | 50% (1 every 5 years, exact tooth) |
| Endodontics | |||
| Anterior root canal therapy (D3310) | $195/$268 copay (1 per lifetime, exact tooth) | 50% (no frequency limit) | 50% (no frequency limit) |
| Molar root canal therapy (D3330) | $335/$425 copay (1 per lifetime, exact tooth) | 50% (no frequency limit) | 50% (no frequency limit) |
| Periodontics | |||
| Osseous surgery/four or more teeth per quadrant (D4260) | $293 copay (1 every 36 months, exact tooth) | 50% (1 every 36 months, exact tooth) | 50% (1 every 36 months, exact tooth) |
| Periodontal scaling and root planing/four or more teeth per quadrant (D4341) | $45 copay (1 every 12 months, exact tooth) | 50% (1 every 24 months, exact tooth) | 50% (1 every 24 months, exact tooth) |
| Prosthetics | |||
| Bridge pontic/false tooth – porcelain fused to high noble metal (per unit) (D6240) | $210 copay (1 per plan year, exact tooth, every 5 years) | 50% (1 every 60 months, exact tooth) | 50% (1 every 60 months, exact tooth) |
| Bridge retainer – crown porcelain fused to high noble metal (per unit) (D6750) | $275 copay (1 per plan year, exact tooth, every 5 years) | 50% (1 every 60 months, exact tooth) | 50% (1 every 60 months, exact tooth) |
| Complete denture (upper or lower) (D5110 or D5120) | $285 copay (1 per plan year, every 5 years) | 50% (1 every 60 months) | 50% (1 every 60 months) |
| Implant services | |||
| Prefabricated abutment – includes modification and placement (D6056) | None | 50% (1 every 60 months) | 50% (1 every 60 months) |
| Oral surgery | |||
| Extraction (single erupted tooth) (D7111) | $10 copay (1 per lifetime, exact tooth) | 50% (2 per lifetime, exact tooth) | 50% (2 per lifetime, exact tooth) |
| Removal of impacted tooth (complete bony) (D7240) | $80 copay (1 per lifetime, exact tooth) | 50% (2 per lifetime, exact tooth) | 50% (2 per lifetime, exact tooth) |
We want your client to keep smiling, so instruct your client to complete the Optional Supplemental Dental HMO or PPO enrollment form today!
1 The Optional Supplemental Dental HMO plan is not available to Blue Shield AdvantageOptimum Plan (HMO), Blue Shield AdvantageOptimum Plan 1 (HMO), Blue Shield Inspire (HMO D-DNP), Blue Shield Select (PPO), and Blue Shield TotalDual Plan (HMO D-SNP) members, and Blue Shield 65 Plus (HMO) members in San Luis Obispo and Santa Barbara counties. The Optional Supplemental Dental PPO plan is not available to Blue Shield AdvantageOptimum Plan, Blue Shield AdvantageOptimum Plan 1, Blue Shield TotalDual Plan, and Blue Shield Inspire (HMO D-SNP) members.
2 All Optional Supplemental Dental HMO services must be performed, prescribed, or authorized by a network dentist. If your client needs to see a specialist, they must get a referral from their primary dentist to receive covered specialist services.
3 ADA codes are procedure codes established by the American Dental Association for efficient processing and reporting of dental claims.
This information is not a complete description of benefits. Contact Customer Service at (800) 776-4466 (TTY 711), for more information. Members must continue to pay their Medicare Part B premium and, if applicable, their Blue Shield Medicare Advantage Plan premium, in addition to the Optional Supplemental Dental HMO or PPO plan premium.
The company complies with applicable state laws and federal civil rights laws and does not discriminate, exclude people, or treat them differently on the basis of race, color, national origin, ethnic group identification, medical condition, genetic information, ancestry, religion, sex, marital status, gender, gender identity, sexual orientation, age, mental disability, or physical disability. La compañía cumple con las leyes de derechos civiles federales y estatales aplicables, y no discrimina, ni excluye ni trata de manera diferente a las personas por su raza, color, país de origen, identificación con determinado grupo étnico, condición médica, información genética, ascendencia, religión, sexo, estado civil, género, identidad de género, orientación sexual, edad, ni discapacidad física ni mental. 本公司遵守適用的州法律和聯邦民權法律，並且不會以種族、膚色、原國籍、族群認同、醫療狀況、遺傳資訊、血統、宗教、性別、婚姻狀況、性別認同、性取向、年齡、精神殘疾或身體殘疾而進行歧視、排斥或區別對待他人。
Page last updated 10/1/2024
Y0118_24_410A_C 08082024
H2819_24_410A_C 08082024
