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Below explanation is for California plan only

Blue Shield Dental logo  Blue Shield Med Supp Dental Insurance 
(877)566-5454 Toll Free
BLUE SHIELD MED SUPP DENTAL PLANS MONTHLY RATES effective 1/01/2012
 
Specialty Duo
Dental & Vision
Package *
Dental PPO 1500
Dental PPO 1000
PREMIUMS PER MONTH
Member Pays
Member Pays
Member Pays
Adult $57.50 $44.00 $35.00
Adult & Spouse/domestic partner $115.00 $88.00 $70.00
Calendar-year deductible per person $50 $50 $75
Calendar-year maximum per person $1500 $1500 $1000
Must have Blue Shield Med Supp Insurance Yes Yes Yes
SIDE-BY-SIDE COMPARISON OF THE PLANS
WAITING PERIODS
Diagnostic & preventive services 0 months 0 months 0 months
Basic Services 0 months 0 months 0 months
Major Services 12 months 12 months 12 months
Benefits - using in-network dentists
DIAGNOSTIC & PREVENTIVE CARE                                            (MAC ¹ payments shown below are for Southern California)
Annual exam & six-month checkups $0 $0 $0
3 Annual cleanings $0 $0 $0
X-rays $0 $0 $0
BASIC SERVICES
20% of MAC ¹
20% of MAC ¹
50% of MAC ¹
Composite filling 1 surface (resin) $16.20 $16.20 $40.50
Composite filling 2 surfaces (resin) $24.40 $24.40 $61.00
MAJOR SERVICES
50% of MAC ¹
50% of MAC ¹
50% of MAC ¹
Periodontal root planing per quadrant $67.50 ² $67.50 ² $67.50 ²
Crown (porcelain fused to noble metal) $297.00 $297.00 $297.00
Osseous surgery per quadrant $327.50 $327.50 $327.50
Anterior root canal $186.50 $186.50 $186.50
Molar root canal $280.00 $280.00 $280.00
Single tooth extraction $38.50 $38.50 $38.50
Removal of impacted tooth (complete bony) $140.50 $140.50 $140.50
Bridge retainer/unit $297 $297 $297
Bridge Pontic/false tooth/unit $267 $267 $267
Complete denture - upper or lower $382 $382 $382

* 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 MAC is the Maximum Allowable Charge of providers in the area. MAC payments shown are for Southern California as listed in the 2011 National Dental Advisory Service Fee Information publication. They are an estimate for illustrative purposes, based on fees negotiated with dentists participating in the network. The member's dentist may have negotiated a different fee. The MAC may be updated periodically and is subject to change. When a member uses a non-network dentist, the plan reimburses up to the MAC amount; if that provider charges more that the MAC rates, the member is responsible for the difference.
² Specialty Duo package for Medicare Supplement plan members, Dental PPO 1000 and Dental 1500 plan have a 12-month waiting period for major restorative services and procedures (such as crowns), Endodontics, Periodontics, oral surgery, and removable or fixed prosthetics.

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Download Blue Shield of California Med Supp 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

Or you can fill in this form to have your Blue Shield Med Supp 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).
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(over age 65)
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Dental Plan Choice

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Have you any comments or special instructions?

 

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.

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Phone:   (760) 433-0300    |   Fax:   (760) 433-0304
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