2022 DENTAL BENEFITS GUIDE - BLUECARE PLUS (HMO D-SNP)SM BLUECARE PLUS CHOICE (HMO D-SNP)SM - BLUECARE PLUS DSNP
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BlueCare Plus (HMO D-SNP)SM
BlueCare Plus Choice (HMO D-SNP)SM
2022 Dental Benefits Guide
H3259_22DENPG_C (08/21)This guide has info you need about your dental benefits,
including what’s covered and how often you can get
covered dental care. To see the full details, look in your
Evidence of Coverage (EOC).
You can find the EOC online at
bluecareplus.bcbst.com/yourmaterials.
Questions? Give us a call.
1-800-332-5762, TTY 711
We’re here to help.
From Oct. 1 to March 31, you can call us seven days a week from 8 a.m. to 9 p.m. ET. From April 1
to Sept. 30, you can call us Monday through Friday from 8 a.m. to 9 p.m. ET. Our automated phone
system may answer your call outside of these hours and during holidays.
All services may not be covered — give us a call for more information. If you move from one dentist
to another during one treatment, or if more than one dentist gives you care for one procedure, we’ll
only cover the cost of one dentist’s care. Make sure you visit an in-network provider. Services at an
out-of-network provider won’t be covered. You don’t have to get prior authorization for any procedure,
but you should check with us first for treatments where the total charges may be more than $200.
You’ll have to pay for any non-covered services. If the services you get cost more than your maximum
allowed amount, you’ll be responsible for any extra charges. These benefits are subject to the Benefits
Chart (what is covered) section of the Evidence of Coverage.Covered Dental Services
Coverage A
One periodic exam every six months
Exams and
One emergency exam every 12 months
Cleaning
One cleaning or periodontal maintenance visit every six months
1 set (up to 4) of bitewing films every 12 months
X-rays
1 panoramic X-ray OR full mouth set of X-rays in 36 months
Coverage B
Restorative Amalgam and composite filling
Services Palliative treatment (emergency relief of pain)
Endodontics
Root canal treatment
(pulp of teeth)
Periodontics Full mouth debridement
(tissue and bone that
Periodontal scaling and root planning
supports teeth)
Oral Surgery Extractions; oral surgery
Coverage C
Major Restorative Removable full and partial dentures
and Prosthodontics Crowns and fixed bridge
Denture, reline or rebase
This is a summary of your dental benefits. To see the full details, look in your
Evidence of Coverage (EOC) or the next pages in this guide.
bluecareplus.bcbst.com | 1Covered Services,
Limitations and Exclusions
Coverage A /Preventive Services
Exams procedures are subject to additional
Covered: Standard exams, including limitations listed below under Basic
comprehensive, periodic, detailed/ Periodontics found under Coverage B.
extensive and periodontal oral No more than one fluoride treatment every
evaluations (exams). Emergency 12 months for members under age 19.
exams, limited oral evaluations (exams). Fluoride must be applied separately from
Limitations: No more than one periodic cleaning paste.
exam every 6 months. No more than X-rays
one emergency exam every 12 months. Covered: Full mouth series, intraoral and
No more than one comprehensive, bitewing radiographs (X-rays).
detailed/extensive or periodontal Limitations: No more than one full mouth
exam every 36 months. set of X-rays every 36 months. A full
Exclusions: Re-evaluations and mouth set of X-rays is either an intraoral
consultations. complete series or panoramic X-ray.
Cleanings, Fluoride Treatment Benefits provided for either include all
Covered: Adult and child prophylaxis necessary intraoral and bitewing films
(cleaning). Child and adult fluoride taken on the same day. No more than four
treatments, performed with or without bitewing films every 12 months. Bitewing
a cleaning. films must be taken on the same date.
Limitations: No more than one cleaning Exclusions: Extraoral, skull and
or periodontal maintenance procedure bone survey, sialography, TMJ, and
every 6 months. Periodontal maintenance tomographic survey X-ray films,
2 | bluecareplus.bcbst.comcephalometric films and diagnostic per denture every 24 months.
photographs. Cephalometric films and Excluded: Gold foil restorations.
diagnostic photographs may be covered Basic Endodontics
as orthodontic benefits under Coverage D. Covered: Pulpotomy, pulpal therapy. The
Other Preventive Services benefits for basic endodontic treatment
Covered: Some preventive services, include X-rays, pulp vitality tests and
including sealants, space maintainers. sedative fillings provided with basic
Limitations: No more than one endodontic treatment.
recementation every 12 months. Limitations: For primary teeth only.
Exclusions: Nutritional and tobacco Not covered when performed with
counseling, oral hygiene instructions. major endodontic treatment.
Exclusions: Pulpal debridement.
Coverage B Major Endodontics
Covered: Root canal treatment and
Basic Restorative Services re-treatment, apexification,
Covered: Amalgam restorations, silver apicoectomy services, root
fillings, resin composite restorations amputation, retrograde filling,
(tooth-colored fillings), stainless steel hemisection, pulp cap. The benefits for
crowns. Emergency pain relief. Repair major endodontic treatment include
of full and partial dentures. X-rays, pulp vitality tests, pulpotomy,
Limitations: No more than one amalgam pulpectomy and sedative filings, and
or resin restoration per tooth surface temporary filling material provided
every 12 months. Replacement of existing with major endodontic treatment.
amalgam and resin composite restorations Limitations: No more than one
covered only after 12 months from the root canal treatment, re-treatment
date of initial restoration. Replacement or apexification per tooth every
of stainless steel crowns covered only 60 months. No more than one
after 36 months from the date of initial apicoectomy per root per lifetime.
restoration. No more than one repair Exclusions: Implantation, canal
bluecareplus.bcbst.com | 3Covered Services,
Limitations and Exclusions
preparation and incomplete than one of these procedures is performed
endodontic therapy. on the same day.
Exclusions: Provisional splinting, scaling
Basic Periodontics
in the presence of gingival inflammation,
Covered: Some non-surgical periodontics,
antimicrobial medication and dressing
including periodontal scaling and root
changes.
planing, full mouth debridement and
periodontal maintenance. Major Periodontics
Limitations: No more than one periodontal Covered: Some surgical periodontics,
scaling and root planing per quadrant including gingivectomy, gingivoplasty,
every 24 months. No more than one gingival flap procedure, crown
full mouth debridement per lifetime. No lengthening, osseous surgery, and bone
more than one cleaning or periodontal and tissue grafting. Benefits provided
maintenance procedure every 6 months. for major periodontics include services
Cleanings are subject to additional related to 90 days of postoperative care.
limitations listed under Coverage A/ Limitations: No more than one major
Preventive Services, and may be subject periodontal surgical procedure every
to a different coverage level under your 36 months.
EOC. Benefits for periodontal maintenance Exclusions: Tissue regeneration and
are provided only after active periodontal apically positioned flap procedure.
treatment (surgical or non-surgical), and Basic Oral Surgery
no sooner than 90 days after completion Covered: Some non-surgical or simple
of the treatment. Benefits for periodontal extractions. Benefits provided for
scaling and root planing, full mouth basic oral surgery include suturing and
debridement, periodontal maintenance postoperative care.
and prophylaxis are not provided if more Exclusions: General anesthesia or
4 | bluecareplus.bcbst.comintravenous sedation when performed resin and porcelain) and veneers.
with basic oral surgery. Limitations: Only for the treatment of
Major Oral Surgery severe carious lesions or severe fracture
Covered: Some surgical extractions on permanent teeth, and only when the
(including removal of impacted teeth and teeth can’t be adequately restored with an
wisdom teeth) and other oral surgical amalgam or resin composite restoration
procedures. Benefits provided for major (filling). For permanent teeth only.
oral surgery include local anesthesia, Replacement of single tooth restorations
suturing and postoperative care. covered only after 60 months
Limitations: Benefits for general from the date of initial placement.
anesthesia or intravenous (IV) sedation Exclusions: Provisional restorations and
are provided only with major oral surgery crowns. Cast crowns or laminate veneers
procedures and only when provided by for members age 11 and under.
a dentist licensed to administer them. Prosthodontic Services
Exclusions: Oral surgery typically covered Covered: Complete, immediate and
under a medical plan, including but not partial dentures.
limited to, excision of lesions and bone Limitations: While constructing a denture,
tissue, treatment of fractures, suturing, if the member and dentist decide on
wound and other repair procedures, a personalized restoration or to use a
TMJ and related procedures. special technique, the benefits will only
Orthognathic surgery and treatment cover the standard procedure or materials.
for congenital malformations. Replacement of removable dentures
covered only after 60 months from the
Coverage C date of initial placement.
Exclusions: Interim (temporary) dentures.
Major Restorative Services
Covered: Some single tooth restorations, Other Major Restorative and
including crowns (resin, porcelain, ¾ cast Prosthodontic Services
and full cast), inlays and onlays (metallic, Covered: Some crown and bridge
bluecareplus.bcbst.com | 5Covered Services,
Limitations and Exclusions
services, including core buildups, post only after 6 months from the date of initial
and core, recementation and repair. placement. No more than one denture
Denture services, including adjustment, reline or rebase every 36 months.
relining, rebasing and tissue connecting. Exclusions: Other major restorative
Implants are covered once per lifetime. services, including sedative fillings and
Implant supported prosthesis is limited to coping. Other prosthodontic services,
1 in 60 months. The benefits provided for including overdenture, precision
crown and bridge restorations include the attachments, connector bard, stress
services of crown preparation, temporary breakers and coping metal.
or prefabricated crowns, impressions and Other Exclusions From Coverage
cementation. Regardless of any other reference in this
Limitations: Benefits won’t be provided Dental Product Guide, benefits are not
for a core build-up separate from those provided for any of the following:
provided for crown construction, except in 1) Dental services received from a dental
circumstances where benefits are provided or medical department maintained by or
for a crown because of severe carious on behalf of an employer, mutual benefit
lesions or a fracture so extensive that association, labor union, trustee or similar
retaining the crown wouldn’t be possible. person or group;
Post and core services are covered only 2) Charges for services performed by you
when performed with a covered crown or your spouse, or your or your spouse’s
or bridge. Crown and bridge repair and parent, sister, brother or child;
recementation are covered separately 3) Services rendered by a dentist beyond
only after 12 months from the date of the scope of his or her license;
initial placement. Denture adjustments 4) Dental services which are free, or
are covered separately from the denture for which you aren’t required or legally
6 | bluecareplus.bcbst.comobligated to pay for, or for which no that doesn’t offer a favorable prognosis,
charge would be imposed if you had that doesn’t meet generally accepted
no dental coverage; standards of professional dental care,
5) Dental services to the extent that or that is experimental in nature;
charges for such services exceed the 12) Services or supplies for the
charge that would have been made treatment of work-related illness or
and collected if no coverage existed injury, regardless of the presence or
hereunder; absence of workers’ compensation
6) Dental services covered by any coverage. This exclusion doesn’t apply
medical insurance coverage, or by any to injuries or illnesses of an employee
other non-dental contract or certificate who is (1) a sole-proprietor of the
issued by BlueCare Plus Tennessee or group; (2) a partner of the group; or (3) a
any other insurance company, carrier, or corporate officer of the group, provided
plan. For example, removal of impacted the officer filed an election not to
teeth, tumors of lip and gum, accidental accept Workers’ Compensation with the
injuries to the teeth, etc.; appropriate government department;
7) Any court-ordered treatment, 13) Charges for any services rendered
unless benefits are otherwise in a hospital or other surgical treatment
payable; facility and any additional fees charged
8) Courses of treatment started before by a dentist for treatment in any such
you became covered under this plan; facility;
9) Any services performed after you’re 14) Dental services with respect to
no longer covered by this plan; congenital malformations or primarily
10) Dental care or treatment not for cosmetic or aesthetic purposes. This
specifically listed in your Evidence of doesn’t exclude those services provided
Coverage as being covered; under orthodontic benefits (if applicable);
11) Any treatment or service that the plan 15) Replacement of tooth structure
determines isn’t necessary dental care, lost from wear or attrition;
bluecareplus.bcbst.com | 7Covered Services,
Limitations and Exclusions
16) Dental services resulting from loss
or theft of a denture, crown, bridge or
removable orthodontic appliance;
17) Diagnosis for, or fabrication of,
appliances or restorations necessary to
correct bite problems, or to restore the
occlusion or correct temporomandibular
joint dysfunction (TMJ) or associated
muscles;
18) Diagnostic dental services, such
as diagnostic tests and oral pathology
services;
19) Adjunctive dental services, including all
local and general anesthesia, sedation, and
analgesia (except as provided under major
oral surgery);
20) Charges for the treatment of desensitizing
medicaments, drugs, occlusal guards and
adjustments, mouthguards, microabrasion,
behavior management and bleaching;
21) Charges for the treatment of professional
visits outside the dental office or after regularly
scheduled hours or for observation.
8 | bluecareplus.bcbst.comFor you. With you.
We’re right here.
Questions? Please call us.
1-800-332-5762, TTY 711
bluecareplus.bcbst.com
1 Cameron Hill Circle | Chattanooga, TN 37402
This document has been classified as public information. BlueCare Plus Tennessee does not discriminate on the
basis of race, color, national origin, sex, age, or disability in its health programs and activities. ATENCIÓN: si habla
español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-800-332-5762, TTY 711.
. فإن خدمات المساعدة اللغوية تتوفر لك بالمجان، إذا كنت تتحدث اللغة العربية:ملحوظة
.TTY 711, 1-800-332-5762 اتصل برقم
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