INDIVIDUAL BLUEDENTAL PREFERRED 2021 - MARYLAND WASHINGTON, D.C. NORTHERN VIRGINIA - CAREFIRST
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Individual BlueDental
Preferred 2021
MARYLAND WASHINGTON, D.C. NORTHERN VIRGINIA
Welcome
Your smile says a lot about you. It’s the first thing
people see when they meet you. A healthy smile
can make you feel more appealing, even more
youthful. But did you know your smile also says a
lot about your overall health?
That’s why it’s so important to protect your smile.
Good dental care has been shown to significantly
reduce your risk of heart disease. It helps control
diabetes, and some studies show it prevents
premature births.
We’re pleased to introduce you to
BlueDental Preferred.
As a member, you’ll enjoy:
■■ Two different deductible options to suit your
budget
■■ Access to more than 5,000 dentists
throughout Maryland, Washington, D.C. and
Northern Virginia, and to a national network
of 123,000 dentists and specialists
■■ Coverage for numerous dental services
■■ No referrals
■■ o charge for oral exams, cleanings and
N
X-rays when you visit an in-network provider
■■ No claim forms to file in-network Did You Know...
■■ A medically necessary orthodontia benefit— ■■ Research suggests
for children up to age 19 that heart disease,
■■ Guaranteed acceptance clogged arteries and
stroke may be linked
■■ o charge for in-network covered services for
N to the inflammation
members age 19 and under after they reach and infections that oral
their $350 out-of-pocket maximum. bacteria can cause.1
Read on to learn about BlueDental Preferred, ■■ Diabetic patients with
offered by CareFirst BlueCross BlueShield gum disease have a
harder time controlling
(CareFirst). Or, contact our product consultants
their blood sugar levels.1
at 855-503-4862, Monday–Thursday, 8 a.m. to
5 p.m. and Friday, 10 a.m. to 5 p.m. ■■ Periodontal disease
has been linked to
premature birth and low
birth weight.1
1
www.mayoclinic.org/healthy-lifestyle/adult-health/in-depth/dental/art-20047475, June 4, 2019
Individual BlueDental Preferred 2021 ■ 1
Contents Welcome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 How Your Plan Works Your Dental Plan Options . . . . . . . . . . . . . . . . . . . . . 3 BlueDental Preferred High Option Summary of Benefits (for members under age 19) . . . . . . . . . 4 BlueDental Preferred High Option Summary of Benefits (for members over age 19) . . . . . . . . . . 5 BlueDental Preferred Low Option Summary of Benefits (for members under age 19) . . . . . . . . . 6 BlueDental Preferred Low Option Summary of Benefits (for members over age 19) . . . . . . . . . . 7 Frequently Used Benefits . . . . . . . . . . . . . . . . . . . . . 8 2021 Monthly Dental Rates . . . . . . . . . . . . . . . . . . . . 9 Enroll Today Enrolling in Your New Dental Plan . . . . . . . . . . . . . 11 Maryland Resident Application . . . . . . . . . . . . . . . . 15 Washington, D.C. Resident Application . . . . . . . . . 17 Northern Virginia Resident Application . . . . . . . . . 19 Additional Information Exclusions and Limitations . . . . . . . . . . . . . . . . . . . 21 Notice of Nondiscrimination and Availability of Language Assistance Services . . . . 26 The policies may have exclusions, limitations or terms under which the policy may be continued in force or discontinued. For costs and complete details of the coverage, call your insurance agent or CareFirst. 2 ■ 855-503-4862 ■ carefirst.com/shopdental
How Your Plan Works
Your Dental Plan Options
We offer two BlueDental Preferred options: High Option and Low Option. The High Option
has lower deductibles with preventive and diagnostic services covered in full when received
from in-network provider without requiring you to meet a deductible. The Low Option has
lower premiums with slightly higher deductibles. The following pages can help you decide
which BlueDental Preferred option is right for you.
BlueDental Preferred includes: BlueDental Preferred has a large
Preventive and diagnostic services (Class I) network of providers
■■ Oral examinations As a member, you’ll enjoy access to more
than 5,000 dentists throughout Maryland,
■■ Cleanings
Washington, D.C. and Northern Virginia, and
■■ X-rays access to a national network of 123,000 dentists
■■ Fluoride treatments for children and specialists. To locate a participating provider,
go to carefirst.com/findadoc and select Preferred
If you pick the High Option, there is no deductible
Dental (PPO & Pediatrics) from the All Plans drop-
or charge for the above services if you visit an in-
down menu.
network provider. If you pick the Low Option, you
can receive these services but will pay in full unless You also have the option to see non-participating
you’ve already met your deductible. providers. If you visit a non-participating provider,
CareFirst will pay a percentage of the allowed
Basic and major services (Classes II, III, IV)
benefit,* but you may be responsible for the
After meeting the deductible, both plans cover difference in cost between the CareFirst allowed
fillings, simple extractions, periodontal scaling, root benefit and your dental provider’s full charge—
planing, root canals, oral surgery, dentures, crowns in addition to any applicable deductibles and
and more! coinsurance. You may also be required to pay up
Orthodontia (Class V) front at the time of service and submit a claim form
to be reimbursed for covered services.
BlueDental Preferred offers benefits for braces
when medically necessary for children up to age 19.
*Allowed benefit—the fee that providers in the network have agreed to accept for a particular service. For
example: Dr. Smith charges $100 to see a patient. To be included in-network, he has agreed to accept $50
for the visit. After the member pays their copay or deductible, CareFirst will pay what’s left of the $50 charge.
A participating provider cannot charge a member more than the allowed benefit (in this example $50) for
any covered service.
Individual BlueDental Preferred 2021 ■ 3BlueDental Preferred High Option Summary of Benefits
(for members under age 19)
In-Network Out-of-Network
Member Pays Member Pays
DEDUCTIBLE APPLIES TO CLASSES II, III, IV
■■ The family deductible amount is calculated in aggregate. However, no family $50 Individual $100 Individual
member will be charged more than the individual deductible amount. deductible; deductible;
■■ The in-network and out-of-network deductible will be a separate amount. $150 Family deductible $300 Family deductible
OUT-OF-POCKET MAXIMUM (CLASSES I–V) One member pays No limit
up to $350;
Two or more members
pay up to $700
PREVENTIVE & DIAGNOSTIC SERVICES (CLASS I)
■■ ral exams (one per six months)
O ■■ ull mouth X-ray or panograph and
F No charge 20% of allowed benefit2
■■ Prophylaxis (one cleaning per six bitewing X-ray combination and one
months) cephalometric X-ray1
■■ Bitewing X-rays (one per ■■ Sealants on permanent molars1
six months) until the end of the year in which
■■ Fluoride treatments1 until the end of member reaches age 19
the year in which member reaches ■■ Space maintainers1
age 19 ■■ Palliative treatments
■■ Emergency oral exam
BASIC SERVICES (CLASS II)
■■ Direct placement fillings using ■■ Periodontal scaling and root planing 20% of allowed benefit2 40% of allowed benefit2
approved materials1 (once per 24 months, one full mouth after deductible after deductible
■■ Simple extractions treatment)
MAJOR SERVICES—SURGICAL (CLASS III)
■■ Surgical periodontic services ■■ ral surgery (surgical extractions,
O 20% of allowed benefit2 40% of allowed benefit2
including osseous surgery and treatment for cysts, tumor and after deductible after deductible
occlusal adjustments1 abscesses, vestibuloplasty and
■■ Endodontics (treatment as required hemi-section)
involving the root and pulp of the ■■ General anesthesia required for
tooth, such as root canal therapy) oral surgery
MAJOR SERVICES—RESTORATIVE (CLASS IV)
■■ ull and/or partial dentures
F ■■ Denture adjustments and relining1 50% of allowed benefit2 65% of allowed benefit2
(once per 60 months) ■■ Dental implants3, subject to after deductible after deductible
■■ Fixed bridges3, crowns, inlays and medical necessity review (once per
onlays (once per 60 months) 60 months)
■■ Recementation of crowns,
inlays and/or bridges (once per
12 months)
ORTHODONTIC SERVICES (CLASS V)
■■ enefits for medically necessary orthodontic services are available for
B 50% of allowed benefit2 65% of allowed benefit2
covered members until the end of the calendar year in which a member
reaches the age of 19.
Summary of Exclusions: Not all services and procedures are covered by your benefits contract. The plan summary is for comparison
purposes only and does not create rights not given through the benefit plan.
1
Frequency limitations may apply.
2
areFirst payments are based on the CareFirst allowed benefit. Participating and preferred dentists accept 100% of the CareFirst allowed
C
benefit as payment in full for covered services. Non-participating dentists may bill the members for the difference between the allowed
benefit and their charges.
3
In Maryland, only covered for members age 19 and over. In Washington, D.C. and VA, covered for all members.
4 ■ 855-503-4862 ■ carefirst.com/shopdentalBlueDental Preferred High Option Summary of Benefits
(for members over age 19)
In-Network Out-of-Network
Member Pays Member Pays
DEDUCTIBLE APPLIES TO CLASSES II, III, IV
■■ The family deductible amount is calculated in aggregate. However, no family $50 Individual $100 Individual
member will be charged more than the individual deductible amount. deductible; deductible;
■■ The in-network and out-of-network deductible will be a separate amount. $150 Family deductible $300 Family deductible
ANNUAL MAXIMUM (CLASSES I–IV)
■■ The in-network and out-of-network annual maximum is a combined amount. Plan pays up to $1,750 per member
PREVENTIVE & DIAGNOSTIC SERVICES (CLASS I)
■■ ral exams (one per six months)
O ■■ ull mouth X-ray or panograph and
F No charge 20% of allowed benefit2
■■ Prophylaxis (one cleaning per six bitewing X-ray combination and one
months) cephalometric X-ray1
■■ Bitewing X-rays (one per ■■ Palliative treatments
six months) ■■ Emergency oral exam
BASIC SERVICES (CLASS II)
■■ Direct placement fillings using ■■ Periodontal scaling and root planing 20% of allowed benefit2 40% of allowed benefit2
approved materials1 (once per 24 months, one full mouth after deductible after deductible
■■ Simple extractions treatment)
MAJOR SERVICES—SURGICAL (CLASS III)
■■ Surgical periodontic services ■■ ral surgery (surgical extractions,
O 40% of allowed benefit2 50% of allowed benefit2
including osseous surgery and treatment for cysts, tumor and after deductible after deductible
occlusal adjustments1 abscesses, vestibuloplasty and
■■ Endodontics (treatment as required hemi-section)
involving the root and pulp of the ■■ General anesthesia required for
tooth, such as root canal therapy) oral surgery
MAJOR SERVICES—RESTORATIVE (CLASS IV)
■■ ull and/or partial dentures
F ■■ Denture adjustments and relining1 50% of allowed benefit2 65% of allowed benefit2
(once per 60 months) ■■ Repair of prosthetic appliances as after deductible after deductible
■■ Fixed bridges3, crowns, inlays and required (once in any 12-month
onlays (once per 60 months) period per specific area of appliance
■■ Recementation of crowns, for members over age 19)
inlays and/or bridges (once per ■■ Dental implants3, subject to
12 months) medical necessity review (once per
60 months)
Summary of Exclusions: Not all services and procedures are covered by your benefits contract. The plan summary is for comparison
purposes only and does not create rights not given through the benefit plan.
1
Frequency limitations may apply.
2
areFirst payments are based on the CareFirst allowed benefit. Participating and preferred dentists accept 100% of the CareFirst allowed
C
benefit as payment in full for covered services. Non-participating dentists may bill the members for the difference between the allowed
benefit and their charges.
3
In Maryland, only covered for members age 19 and over. In Washington, D.C. and VA, covered for all members.
855-503-4862 ■ carefirst.com/shopdental ■ 5BlueDental Preferred Low Option Summary of Benefits
(for members under age 19)
In-Network Out-of-Network
Member Pays Member Pays
DEDUCTIBLE APPLIES TO CLASSES I–IV
■■ The family deductible amount is calculated in aggregate. However, no family $100 Individual $200 Individual
member will be charged more than the individual deductible amount. deductible; deductible;
■■ The in-network and out-of-network deductible will be a separate amount. $300 Family deductible $600 Family deductible
OUT-OF-POCKET MAXIMUM (CLASSES I–V) One member pays No limit
up to $350;
Two or more members
pay up to $700
PREVENTIVE & DIAGNOSTIC SERVICES (CLASS I)
■■ ral exams (one per six months)
O ■■ ull mouth X-ray or panograph and
F No charge after 20% of allowed benefit2
■■ Prophylaxis (one cleaning per six bitewing X-ray combination and one deductible after deductible
months) cephalometric X-ray1
■■ Bitewing X-rays (one per ■■ Sealants on permanent molars1
six months) until the end of the year in which
■■ Fluoride treatments1 until the end of member reaches age 19
the year in which member reaches ■■ Space maintainers1
age 19 ■■ Palliative treatments
■■ Emergency oral exam
BASIC SERVICES (CLASS II)
■■ Direct placement fillings using ■■ Periodontal scaling and root planing 20% of allowed benefit2 40% of allowed benefit2
approved materials1 (once per 24 months, one full mouth after deductible after deductible
■■ Simple extractions treatment)
MAJOR SERVICES—SURGICAL (CLASS III)
■■ Surgical periodontic services ■■ ral surgery (surgical extractions,
O 20% of allowed benefit2 40% of allowed benefit2
including osseous surgery and treatment for cysts, tumor and after deductible after deductible
occlusal adjustments1 abscesses, vestibuloplasty and
■■ Endodontics (treatment as required hemi-section)
involving the root and pulp of the ■■ General anesthesia required for
tooth, such as root canal therapy) oral surgery
MAJOR SERVICES—RESTORATIVE (CLASS IV)
■■ ull and/or partial dentures
F ■■ Denture adjustments and relining1 50% of allowed benefit2 65% of allowed benefit2
(once per 60 months) ■■ Dental implants3, subject to after deductible after deductible
■■ Fixed bridges3, crowns, inlays and medical necessity review (once per
onlays (once per 60 months) 60 months)
■■ Recementation of crowns,
inlays and/or bridges (once per
12 months)
ORTHODONTIC SERVICES (CLASS V)
■■ enefits for medically necessary orthodontic services are available for
B 50% of allowed benefit2 65% of allowed benefit2
covered members until the end of the calendar year in which a member
reaches the age of 19.
Summary of Exclusions: Not all services and procedures are covered by your benefits contract. The plan summary is for comparison
purposes only and does not create rights not given through the benefit plan.
1
Frequency limitations may apply.
2
areFirst payments are based on the CareFirst allowed benefit. Participating and preferred dentists accept 100% of the CareFirst allowed
C
benefit as payment in full for covered services. Non-participating dentists may bill the members for the difference between the allowed
benefit and their charges.
3
In Maryland, only covered for members age 19 and over. In Washington, D.C. and VA, covered for all members.
6 ■ 855-503-4862 ■ carefirst.com/shopdentalBlueDental Preferred Low Option Summary of Benefits
(for members over age 19)
In-Network Out-of-Network
Member Pays Member Pays
DEDUCTIBLE APPLIES TO CLASSES I–IV
■■ The family deductible amount is calculated in aggregate. However, no family $100 Individual $200 Individual
member will be charged more than the individual deductible amount. deductible; deductible;
■■ The in-network and out-of-network deductible will be a separate amount. $300 Family deductible $600 Family deductible
ANNUAL MAXIMUM (CLASSES I–IV)
■■ The in-network and out-of-network annual maximum is a combined amount. Plan pays up to $1,250 per member
PREVENTIVE & DIAGNOSTIC SERVICES (CLASS I)
■■ ral exams (one per six months)
O ■■ ull mouth X-ray or panograph and
F No charge after 20% of allowed benefit2
■■ Prophylaxis (one cleaning per six bitewing X-ray combination and one deductible after deductible
months) cephalometric X-ray1
■■ Bitewing X-rays (one per ■■ Palliative treatments
six months) ■■ Emergency oral exam
BASIC SERVICES (CLASS II)
■■ Direct placement fillings using ■■ Periodontal scaling and root planing 20% of allowed benefit2 40% of allowed benefit2
approved materials1 (once per 24 months, one full mouth after deductible after deductible
■■ Simple extractions treatment)
MAJOR SERVICES—SURGICAL (CLASS III)
■■ Surgical periodontic services ■■ ral surgery (surgical extractions,
O 40% of allowed benefit2 50% of allowed benefit2
including osseous surgery and treatment for cysts, tumor and after deductible after deductible
occlusal adjustments1 abscesses, vestibuloplasty and
■■ Endodontics (treatment as required hemi-section)
involving the root and pulp of the ■■ General anesthesia required for
tooth, such as root canal therapy) oral surgery
MAJOR SERVICES—RESTORATIVE (CLASS IV)
■■ ull and/or partial dentures
F ■■ Denture adjustments and relining1 65% of allowed benefit2 75% of allowed benefit2
(once per 60 months) ■■ Repair of prosthetic appliances as after deductible after deductible
■■ Fixed bridges3, crowns, inlays and required (once in any 12-month
onlays (once per 60 months) period per specific area of appliance
■■ Recementation of crowns, for members over age 19)
inlays and/or bridges (once per ■■ Dental implants3, subject to
12 months) medical necessity review (once per
60 months)
Summary of Exclusions: Not all services and procedures are covered by your benefits contract. The plan summary is for comparison
purposes only and does not create rights not given through the benefit plan.
1
Frequency limitations may apply.
2
areFirst payments are based on the CareFirst allowed benefit. Participating and preferred dentists accept 100% of the CareFirst allowed
C
benefit as payment in full for covered services. Non-participating dentists may bill the members for the difference between the allowed
benefit and their charges.
3
In Maryland, only covered for members age 19 and over. In Washington, D.C. and VA, covered for all members.
Individual BlueDental Preferred 2021 ■ 7Frequently Used Benefits
Below is a partial list of the most commonly used member services. These rates show what you could
expect to pay for in-network services. For specific questions, please contact our CareFirst Dental product
consultants team at 855-503-4862.
In-Network You Pay2
Common Dental Procedures Regular Cost1
High Option Low Option
Preventive checkups
including routine exams, cleanings and $206 per visit $0 $0 after deductible
X-rays (2 visits per year)
$11–$17 $11–$17
Fillings and simple extractions $148–$200
after deductible after deductible
Periodontal scaling and root planing $27 $27
$285
(4 or more teeth per quadrant) after deductible after deductible
Root canal therapy $264 $264
$1,183
(molar, excluding final restoration) after deductible after deductible
$354 $460
Porcelain ceramic crown $1,250
after deductible after deductible
$938 $1,219
Bridge (3-unit) $3,758
after deductible after deductible
$334 $435
Complete upper dentures $1,883
after deductible after deductible
Medically necessary orthodontia
$5,512 $1,481 $1,481
(child up to age 19)
1
Based on National Dental Advisory Service Fee Report (2019)
2
Approximate amount for a member over the age of 19. Pricing may vary depending on dental provider’s negotiated rate with CareFirst.
8 ■ 855-503-4862 ■ carefirst.com/shopdental2021 Monthly Dental Rates
Figuring out the total monthly premium for
Maryland
the plans you’re considering is simple:
BlueDental Preferred High Option
1. Based on where you live, find your rate on
the chart below. Ages 0–20 $44.05
2. Circle the amount in the column that Ages 21+ $44.50
corresponds with your age when coverage
will begin. If you’re buying an individual plan, BlueDental Preferred Low Option
that’s it! Ages 0-20 $34.02
3. For a family plan, repeat step 2 for each
family member who will be covered by your Ages 21+ $36.20
new plan and add the numbers up.
4. If you want to pay quarterly, then multiply Washington, D.C.
the monthly total by three. If you want to pay
BlueDental Preferred High Option
annually, multiply the monthly total by 12.
The rates shown reflect the current premium Ages 0–20 $33.28
levels. Your actual premium rate may be higher
Ages 21+ $43.01
than the rate shown based on the date of your
signed application. All rates are subject to change. BlueDental Preferred Low Option
Ages 0-20 $24.19
Ages 21+ $34.39
Virginia
BlueDental Preferred High Option
Ages 0–20 $44.21
Ages 21+ $49.25
BlueDental Preferred Low Option
Ages 0-20 $34.02
Ages 21+ $40.51
855-503-4862 ■ carefirst.com/shopdental ■ 910 ■ 855-503-4862 ■ carefirst.com/shopdental
Enroll Today
Enrolling in Your New Dental Plan
Pick one of these four options to enroll:
Enroll online at carefirst.com/shopdental.
ill out and sign the application that matches where you live—Maryland, Washington,
F
D.C. or Northern Virginia. Be sure to choose the annual or quarterly payment option and
check either the Low Option or High Option deductible plan on the application. Use the
enclosed, postage-paid envelope or your own to mail your application to:
Mail Administrator
P.O. Box 14651
Lexington, KY 40512
nroll online through your state’s Exchange. Exception—these plans are no longer offered
E
on the Virginia Federally-facilitated Exchange, so if you live in Northern Virginia, you must
apply using one of the other three options.
Maryland—marylandhealthconnection.com
Washington, D.C.—dchealthlink.com
Enroll through your broker, if you have one. A broker is an independent agent who
represents you (the buyer) and works to find you the best health insurance policy for
your needs.
you have any questions about the application, contact a product
If
consultant at 855-503-4862, Monday –Thursday, 8 a.m. to 5 p.m. and
Friday, 10 a.m. to 5 p.m.
Applications may be submitted at any time, but to guarantee your When you’re ready to
coverage will be effective the first of the following month, we must review a list of providers,
receive your application before the 20th of the current month. please visit carefirst.com/
For example: if CareFirst receives an application on March 18, findadocdental. Click on
that individual’s coverage starts April 1. If an application does not Preferred Dental (PPO &
reach us until March 25, coverage would not be in effect until May 1. Pediatrics).
Once your application has been received, we will send you a bill for
your first premium payment. We must receive your first premium
payment before your coverage can begin. After CareFirst receives
your payment, you will be mailed your member ID card(s) and your
individual enrollment agreement. Then you can start enjoying the
benefits of good dental care.
Please note: In order to purchase coverage, you must live in
Maryland, Washington, D.C. or one of the following areas of
Northern Virginia: City of Alexandria and Fairfax, the town of
Vienna, Arlington County and the areas of Fairfax and Prince William
counties in Virginia lying east of Route 123.
855-503-4862 ■ carefirst.com/shopdental ■ 1112 ■ 855-503-4862 ■ carefirst.com/shopdental
Individual BlueDental Preferred 2021 ■ 13
Maryland Resident Application
Please fill out the Maryland
BlueDental Preferred
application on the following
pages, if you live in Maryland.
Individual BlueDental Preferred 2021 ■ 15BlueDental Preferred Application
Maryland Residents CareFirst of Maryland, Inc.
10455 Mill Run Circle, Owings Mills, MD 21117
If you live in Baltimore City or any county in the state of Maryland
other than Prince George’s or Montgomery County, please check the Group Hospitalization and Medical Services, Inc.
CareFirst of Maryland, Inc. box to the right. 840 First Street, NE, Washington, DC 20065
If you reside in Prince George’s or Montgomery County, please check A private not-for-profit health service plan.
the Group Hospitalization and Medical Services, Inc. box to the right.
INSTRUCTIONS
1. Please fill out all applicable spaces on this application.
Print or type all information.
2. Sign and return this application in the postage-paid
return envelope, if provided, or mail to:
Mail Administrator
P.O. Box 14651, Lexington, KY 40512
Give careful attention to all questions in this application.
Accurate, complete information is necessary before your Please check if you are applying for new coverage or making
application can be processed. If incomplete, the application changes to a current policy.
will be returned and your coverage will be delayed. New coverage Making changes
1. APPLICANT INFORMATION
Last Name First Name Initial Social Security #
Residence Address (Number and Street, Apt #) City State Zip Code (9-digit, if known)
Billing Address, if different (Number and Street, Apt #) City State Zip Code (9-digit, if known)
Residence County Date of Birth Sex Marital Status
Male Female Single Married Domestic Partner
/ /
Home Phone Work/Mobile Phone Payment Option
( ) ( ) Annually Quarterly
2. DEDUCTIBLE SELECTION (check one)
Low Option ($100 individual in-network deductible) High Option ($50 individual in-network deductible)
3. ENROLLING FAMILY MEMBER(S) (only list family members to be covered on this plan)
Last Name First Name M.I. Relationship Social Security # Date of Birth Sex
Spouse M F
Domestic
Partner M F
Dependent 1 M F
Dependent 2 M F
Dependent 3 M F
Dependent 4 M F
Dependent 5 M F
Dependent 6 M F
Dependent 7 M F
Dependent 8 M F
CareFirst BlueCross BlueShield is the business name of CareFirst of Maryland, Inc. which is an independent licensee of the Blue Cross and Blue Shield Association. The Blue Cross and Blue Shield Names
and Symbols are registered service marks of the Blue Cross and Blue Shield Association. The CareFirst name and logo are registered service marks of Group Hospitalization and Medical Services, Inc.
®’ Registered trademark of CareFirst of Maryland, Inc. If you reside in either Prince George’s or Montgomery county, then a Group Hospitalization and Medical Services, Inc. policy will be issued.
For Baltimore City or any other county in the state of Maryland, a CareFirst of Maryland, Inc. policy will be issued.
DMDAP (5/19) 1 CDS1100-1P (4/19)4. ELECTRONIC COMMUNICATION CONSENT
CareFirst BlueCross BlueShield (CareFirst) wants to help you manage your health care information and protect the
environment by offering you the option of electronic communication.
Instead of paper delivery, you can receive electronic notices about your CareFirst health care coverage through email and/or
text messaging by providing your email address and/or mobile phone number and consent below.
Electronic notices regarding your CareFirst health care coverage include, but are not limited to:
■■ Explanation of Benefits Alerts
■■ Reminders
■■ Notice of HIPAA Privacy Practices
■■ Certification of Creditable Coverage
You may also receive information on programs related to your current plan(s) and services along with new plans and services
that may interest you.
Please note: This consent for electronic communications applies to the primary applicant only. A spouse/domestic partner
and/or dependents 18 years of age and older can consent to electronic communications at carefirst.com/myaccount. You
can also change email and consent information anytime by logging into carefirst.com/myaccount or by calling the customer
service phone number on your member ID card. You can also request a paper copy of electronic notices by calling the
customer service phone number on your member ID card.
I understand that to access the information sent by email, I must have all three of the following:
■■ Internet access
■■ An email account that allows me to send and receive emails
■■ Microsoft Explorer 7.0 (or higher) or Firefox 3.0 (or higher) and Adobe Acrobat Reader 4 (or higher).
I understand that to receive notices by text message:
■■ A text messaging plan with my mobile phone provider is required
■■ Standard text messaging rates will apply
Primary Applicant Name Email Address Mobile Phone Number
Alternate Email Address Alternate Mobile Phone Number
By checking my preference below, I hereby agree to electronic delivery of notices instead of paper delivery.
Email only Mobile phone text messaging only Email and mobile phone text messaging
Signature:
CareFirst will not sell your email or phone number to any third party and will not share it with third parties
except for CareFirst Business Associates that perform functions on CareFirst’s behalf or to comply with the law.
DMDAP (5/19) 2 CDS1100-1P (4/19)5. CONDITIONS OF ENROLLMENT (please read this section carefully)
IT IS UNDERSTOOD AND AGREED THAT:
A copy of this application will be provided to the applicant or application filer.
his information is subject to verification. Failure to complete any section may delay the processing of your application and/
T
or claims payment. If we determine that additional information is needed, you will receive an authorization to release that
information. Failure to execute an authorization may result in the denial of your application for coverage.
Premium payment options are available on an annual or quarterly basis.
o the best of my knowledge and belief, all statements made on this application are complete, true and correctly recorded.
T
They are representations that are made to induce the issuance of, and form part of the consideration
for, a CareFirst policy.
I f you have any questions concerning the benefits and services that are provided by or excluded under this agreement,
please contact a membership services representative toll-free at (866) 891-2802 before signing this application.
WARNING: ANY PERSON WHO KNOWINGLY OR WILLFULLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT
OF A LOSS OR BENEFIT OR WHO KNOWINGLY OR WILLFULLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR
INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN PRISON.
Signature of Primary Applicant Date
NOTE: Applications submitted solely on behalf of applicants under the age of 18, where payment of premium is made by the
parent or legal guardian, must be signed by the parent or legal guardian.
Parent or Legal Guardian’s Signature Date
FOR OFFICE USE ONLY:
Re-sign and re-date below only if checked.
Signature of Primary Applicant Date
Signature of Applicant 2 Date
(Spouse or Domestic Partner)
Parent or Legal Guardian’s Signature Date
For Broker Use Only: Name: NPN # Tax ID # CareFirst-Assigned ID #
General Agency
Writing Agent
DMDAP (5/19) 3 CDS1100-1P (4/19)Washington, D.C. Resident Application
Please fill out the Washington,
D.C. BlueDental Preferred
application on the following
pages, if you live in
Washington, D.C.
Individual BlueDental Preferred 2021 ■ 17BlueDental Preferred Application
Washington, D.C. Residents Group Hospitalization and Medical Services, Inc.
840 First Street, NE, Washington, DC 20065
A private not-for-profit health service plan.
INSTRUCTIONS
1. Please fill out all applicable spaces on this application.
Print or type all information.
2. Sign and return this application in the postage-paid
return envelope, if provided, or mail to:
Mail Administrator
P.O. Box 14651, Lexington, KY 40512
Give careful attention to all questions in this application.
Accurate, complete information is necessary before your Please check if you are applying for new coverage or making
application can be processed. If incomplete, the application changes to a current policy.
will be returned and your coverage will be delayed. New coverage Making changes
1. APPLICANT INFORMATION
Last Name First Name Initial Social Security #
Residence Address (Number and Street, Apt #) City State Zip Code (9-digit, if known)
Billing Address, if different (Number and Street, Apt #) City State Zip Code (9-digit, if known)
Payment Option Date of Birth Sex Marital Status
Annually Quarterly Male Female Single Married Domestic Partner/Other
/ /
Home Phone Work/Mobile Phone
( ) ( )
2. DEDUCTIBLE SELECTION (check one)
Low Option ($100 individual in-network deductible) High Option ($50 individual in-network deductible)
3. ENROLLING FAMILY MEMBER(S) (only list family members to be covered on this plan)
Last Name First Name M.I. Relationship Social Security # Date of Birth Sex
Spouse M F
Domestic/Civil
Union Partner M F
Dependent 1 M F
Dependent 2 M F
Dependent 3 M F
Dependent 4 M F
Dependent 5 M F
Dependent 6 M F
Dependent 7 M F
Dependent 8 M F
CareFirst BlueCross BlueShield is the business name of Group Hospitalization and Medical Services, Inc. which is an independent licensee of the Blue Cross and Blue Shield Association.
The Blue Cross and Blue Shield Names and Symbols are registered service marks of the Blue Cross and Blue Shield Association. The CareFirst name and logo are registered service marks of
Group Hospitalization and Medical Services, Inc.
DDCAP (5/19) 1 CDS1098-1P (4/19)4. ELECTRONIC COMMUNICATION CONSENT
CareFirst BlueCross BlueShield (CareFirst) wants to help you manage your health care information and protect the
environment by offering you the option of electronic communication.
Instead of paper delivery, you can receive electronic notices about your CareFirst health care coverage through email and/or
text messaging by providing your email address and/or mobile phone number and consent below.
Electronic notices regarding your CareFirst health care coverage include, but are not limited to:
■■ Explanation of Benefits Alerts
■■ Reminders
■■ Notice of HIPAA Privacy Practices
■■ Certification of Creditable Coverage
You may also receive information on programs related to your current plan(s) and services along with new plans and services
that may interest you.
Please note: This consent for electronic communications applies to the primary applicant only. A spouse/domestic partner
and/or dependent(s) 18 years of age and older can consent to electronic communications at carefirst.com/myaccount. You
can also change email and consent information anytime by logging into carefirst.com/myaccount or by calling the customer
service phone number on your member ID card. You can also request a paper copy of electronic notices by calling the
customer service phone number on your member ID card.
I understand that to access the information sent by email, I must have all three of the following:
■■ Internet access
■■ An email account that allows me to send and receive emails
■■ Microsoft Explorer 7.0 (or higher) or Firefox 3.0 (or higher) and Adobe Acrobat Reader 4 (or higher)
I understand that to receive notices by text message:
■■ A text messaging plan with my mobile phone provider is required
■■ Standard text messaging rates will apply
Primary Applicant Name Email Address Mobile Phone Number
Alternate Email Address Alternate Mobile Phone Number
By checking my preference below, I hereby agree to electronic delivery of notices instead of paper delivery.
Email only Mobile phone text messaging only Email and mobile phone text messaging
Signature:
CareFirst will not sell your email or phone number to any third party and will not share it with third parties
except for CareFirst Business Associates that perform functions on CareFirst’s behalf or to comply with the law.
DDCAP (5/19) 2 CDS1098-1P (4/19)5. CONDITIONS OF ENROLLMENT (please read this section carefully)
IT IS UNDERSTOOD AND AGREED THAT:
A copy of this application will be provided to the applicant (or to a person authorized to act on his/her behalf).
his information is subject to verification. Failure to complete any section may delay the processing of your application and/
T
or claims payment. If we determine that additional information is needed, you will receive an authorization to release that
information. Failure to execute an authorization may result in the denial of your application for coverage.
Premium payment options are available on an annual and a quarterly basis.
o the best of my knowledge and belief, all statements made on this application are complete, true and correctly recorded.
T
They are representations that are made to induce the issuance of, and form part of the consideration for, a CareFirst policy.
I f you have any questions concerning the benefits and services that are provided by or excluded under this agreement,
please contact a membership services representative toll-free at (888) 892-9901 before signing this application.
WARNING: IT IS A CRIME TO PROVIDE FALSE OR MISLEADING INFORMATION TO AN INSURER FOR THE PURPOSE OF
DEFRAUDING THE INSURER OR ANY OTHER PERSON. PENALTIES INCLUDE IMPRISONMENT AND/OR FINES. IN ADDITION,
AN INSURER MAY DENY INSURANCE BENEFITS IF FALSE INFORMATION MATERIALLY RELATED TO A CLAIM WAS PROVIDED
BY THE APPLICANT.
Signature of Primary Applicant Date
NOTE: Applications submitted solely on behalf of applicants under the age of 18, where payment of premium is made by the
parent or legal guardian, must be signed by the parent or legal guardian.
Parent or Legal Guardian’s Signature Date
FOR OFFICE USE ONLY:
Re-sign and re-date below only if checked.
Signature of Primary Applicant Date
Signature of Applicant 2 Date
(Spouse or Domestic Partner)
Parent or Legal Guardian’s Signature Date
For Broker Use Only: Name: NPN # Tax ID # CareFirst-Assigned ID #
General Agency
Writing Agent
DDCAP (5/19) 3 CDS1098-1P (4/19)Northern Virginia Resident Application
Please fill out the Virginia
BlueDental Preferred
application on the following
pages, if you live in the cities
of Alexandria and Fairfax,
the town of Vienna, Arlington
County and the areas of
Fairfax and Prince William
counties in Virginia lying east
of Route 123.
Individual BlueDental Preferred 2021 ■ 19BlueDental Preferred Application
Virginia Residents Group Hospitalization and Medical Services, Inc.
840 First Street, NE, Washington, DC 20065
A private not-for-profit health service plan.
INSTRUCTIONS
1. Please fill out all applicable spaces on this application.
Print or type all information.
2. Sign and return this application in the postage-paid
return envelope, if provided, or mail to:
Mail Administrator
P.O. Box 14651, Lexington, KY 40512
Give careful attention to all questions in this application.
Accurate, complete information is necessary before your Please check if you are applying for new coverage or making
application can be processed. If incomplete, the application changes to a current policy.
will be returned and your coverage will be delayed. New coverage Making changes
1. APPLICANT INFORMATION
Last Name First Name Initial Social Security #
Residence Address (Number and Street, Apt #) City State Zip Code (9-digit, if known)
Billing Address, if different (Number and Street, Apt #) City State Zip Code (9-digit, if known)
Payment Option Date of Birth Sex Marital Status
Annually Quarterly Male Female Single Married Domestic Partner
/ /
Home Phone Work/Mobile Phone
( ) ( )
2. DEDUCTIBLE SELECTION (check one)
Low Option ($100 individual in-network deductible) High Option ($50 individual in-network deductible)
3. ENROLLING FAMILY MEMBER(S) (only list family members to be covered on this plan)
Last Name First Name M.I. Relationship Social Security # Date of Birth Sex
Spouse M F
Domestic
Partner M F
Dependent 1 M F
Dependent 2 M F
Dependent 3 M F
Dependent 4 M F
Dependent 5 M F
Dependent 6 M F
Dependent 7 M F
Dependent 8 M F
CareFirst BlueCross BlueShield is the business name of Group Hospitalization and Medical Services, Inc. which is an independent licensee of the Blue Cross and Blue Shield Association.
The Blue Cross and Blue Shield Names and Symbols are registered service marks of the Blue Cross and Blue Shield Association. The CareFirst name and logo are registered service marks of
Group Hospitalization and Medical Services, Inc.
DVAAP (5.19) 1 CDS1097-1P (4/19)4. ELECTRONIC COMMUNICATION CONSENT
CareFirst BlueCross BlueShield (CareFirst) wants to help you manage your health care information and protect the
environment by offering you the option of electronic communication.
Instead of paper delivery, you can receive electronic notices about your CareFirst health care coverage through email and/or
text messaging by providing your email address and/or mobile phone number and consent below.
Electronic notices regarding your CareFirst health care coverage include, but are not limited to:
■■ Explanation of Benefits Alerts
■■ Reminders
■■ Notice of HIPAA Privacy Practices
■■ Certification of Creditable Coverage
You may also receive information on programs related to your current plan(s) and services along with new plans and services
that may interest you.
Please note: This consent for electronic communications applies to the primary applicant only. A spouse or domestic partner
and/or dependents 18 years of age and older can consent to electronic communications at carefirst.com/myaccount. You
can also change email and consent information anytime by logging into carefirst.com/myaccount or by calling the customer
service phone number on your member ID card. You can also request a paper copy of electronic notices by calling the
customer service phone number on your member ID card.
I understand that to access the information sent by email, I must have all three of the following:
■■ Internet access
■■ An email account that allows me to send and receive emails
■■ Microsoft Explorer 7.0 (or higher) or Firefox 3.0 (or higher) and Adobe Acrobat Reader 4 (or higher).
I understand that to receive notices by text message:
■■ A text messaging plan with my mobile phone provider is required
■■ Standard text messaging rates will apply
Primary Applicant Name Email Address Mobile Phone Number
Alternate Email Address Alternate Mobile Phone Number
By checking my preference below, I hereby agree to electronic delivery of notices instead of paper delivery.
Email only Mobile phone text messaging only Email and mobile phone text messaging
Signature:
CareFirst will not sell your email or phone number to any third party and will not share it with third parties
except for CareFirst Business Associates that perform functions on CareFirst’s behalf or to comply with the law.
DVAAP (5.19) 2 CDS1097-1P (4/19)5. CONDITIONS OF ENROLLMENT (please read this section carefully)
IT IS UNDERSTOOD AND AGREED THAT:
A copy of this application is available to the applicant (or to a person authorized to act on his/her behalf).
his information is subject to verification. Failure to complete any section may delay the processing of your application and/
T
or claims payment. If we determine that additional information is needed, you will receive an authorization to release that
information. Failure to execute an authorization may result in the denial of your application for coverage.
Premium payment options are available on an annual and a quarterly basis.
o the best of my knowledge and belief, all statements made on this application are complete, true and correctly recorded.
T
They are representations that are made to induce the issuance of, and form part of the consideration for, a CareFirst policy.
I f you have any questions concerning the benefits and services that are provided by or excluded under this agreement,
please contact a membership services representative toll-free at (866) 891-2802 before signing this application.
WARNING: ANY PERSON WHO, WITH THE INTENT TO DEFRAUD OR KNOWING THAT HE IS FACILITATING A FRAUD AGAINST
AN INSURER, SUBMITS AN APPLICATION OR FILES A CLAIM CONTAINING A FALSE OR DECEPTIVE STATEMENT MAY HAVE
VIOLATED VIRGINIA STATE LAW.
The undersigned applicant and agent (if applicable) certify that the applicant has read, or had read to him/her, the completed
application, and that the applicant realizes that any false statement or misrepresentation in the application may result in the
loss of coverage under the policy.
A coordination of benefits may apply as the result of the existence of other similar insurance providing coverage for the
same dental services.
Signature of Primary Applicant Date
NOTE: Applications submitted solely on behalf of applicants under the age of 18, where payment of premium is made by the
parent or legal guardian, must be signed by the parent or legal guardian.
Parent or Legal Guardian’s Signature Date
Signature of Agent (if applicable): Date
FOR OFFICE USE ONLY:
Re-sign and re-date below only if checked.
Signature of Primary Applicant Date
Signature of Applicant 2 Date
(Spouse or Domestic Partner)
Parent or Legal Guardian’s Signature Date
For Broker Use Only: Name: NPN # Tax ID # CareFirst-Assigned ID #
General Agency
Writing Agent
DVAAP (5.19) 3 CDS1097-1P (4/19)Additional Information
Exclusions and Limitations
For Maryland residents: C. Replacement of dentures, bridges, metal
and/or porcelain crowns, inlays, onlays and
3.1 Limitations.
crown build-ups within 60 months from the
A. Covered dental services must be performed date of placement or replacement for which
by or under the supervision of a dentist with benefits were paid in whole or in part under
an active and unrestricted license, within the terms of the dental benefits Agreement
the scope of practice for which licensure or and are judged by CareFirst to be adequate
certification has been obtained. and functional.
B. Benefits will be limited to standard procedures D. Replacement of stainless steel crowns (until the
and will not be provided for personalized end of the calendar year in which the member
restorations or specialized techniques in turns age 19) if judged by CareFirst to be
the construction of dentures or bridges, adequate and functional.
including precision attachments, custom E. Treatment or services for temporomandibular
denture teeth and implant supported fixed or joint (TMJ) disorders, including but not limited
removable prostheses. to radiographs and/or tomographic surveys,
C. If a member switches from one dentist to except for TMJ arthograms, including injection,
another during a course of treatment, or if and other TMJ films, by report, for members up
more than one dentist renders services for one to age 19.
dental procedure, CareFirst shall pay as if only F. Gold foil fillings.
one dentist rendered the service. G. Periodontal appliances.
D. CareFirst will reimburse only after all dental H. Prescription drugs including but not limited
procedures for the condition being treated to antibiotics administered by the member,
have been completed (this provision does not inhalation of nitrous oxide (except for
apply to orthodontic services). members under age 19), injected or applied
E. In the event there are alternative dental medications that are not part of the dental
procedures that meet generally accepted service being rendered, and localized delivery
standards of professional dental care for a of chemotherapeutic agents for the treatment
Member’s condition, benefits will be based of a medical condition, unless specifically
upon the lowest cost alternative. CareFirst listed as a Covered Dental Service in the dental
benefits will cover treatment based upon the benefits Agreement.
CareFirst allowance for the least expensive I. Nightguards for members over age 19 or other
procedure, provided that the least expensive oral orthotic appliances, unless specifically
procedure meets accepted standards of listed as a Covered Dental Service in the dental
professional dental treatment. CareFirst’s benefits Agreement.
decision does not commit the Subscriber to J. Bacteriologic studies, histopathologic exams,
the least expensive procedure. However, if accession of tissue, caries susceptibility
the Subscriber and the dentist choose the tests, diagnostic radiographs and other
more expensive procedure, the Subscriber is pathology procedures, unless specifically
responsible for the additional charges beyond listed as a Covered Dental Service in the dental
those approved or allowed by CareFirst. benefits Agreement.
K. Intentional tooth reimplantation or
3.2 Exclusions. Benefits will not be provided for:
transplantation for members over age 19.
A. Replacement of a denture, bridge or crown L. Interim prosthetic devices (fixed or removable)
as a result of loss or theft. not part of a permanent or restorative
B. Replacement of an existing denture, bridge prosthetic service.
or crown that is determined by CareFirst to be
satisfactory or repairable.
Individual BlueDental Preferred 2021 ■ 21M. Additional fees charged for visits by a dentist to For Washington, D.C. residents:
the member’s home, to a hospital, to a nursing
3.1 Limitations.
home or for office visits after the dentist’s
standard office hours. CareFirst shall provide A. Covered dental services must be performed
the benefits for the dental service as if the visit by or under the supervision of a dentist with
was rendered in the dentist’s office during an active and unrestricted license, within
normal office hours. the scope of practice for which licensure or
N. Transseptal fiberotomy. certification has been obtained.
O. Orthognathic surgery. B. Benefits will be limited to standard procedures
P. The repair or replacement of any orthodontic and will not be provided for personalized
appliance, unless specifically listed as restorations or specialized techniques in
a Covered Dental Service in the dental the construction of dentures or bridges,
benefits Agreement. including precision attachments and custom
Q. Any orthodontic services after the last day of denture teeth.
the month in which Covered Dental Services C. If a member switches from one dentist to
ended, except as specifically described in the another during a course of treatment, or if
dental benefits Agreement. more than one dentist renders services for one
R. Services or supplies that are not medically dental procedure, CareFirst shall pay as if only
necessary as determined by CareFirst. one dentist rendered the service.
S. Services not specifically listed in the dental D. CareFirst will reimburse only after all dental
benefits Agreement as a Covered Dental procedures for the condition being treated
Service, even if medically necessary. have been completed (this provision does not
T. Services or supplies that are related to an apply to orthodontic services).
excluded service (even if those services or E. In the event there are alternative dental
supplies would otherwise be covered services). procedures that meet generally accepted
U. Separate billings for dental care services or standards of professional dental care for a
supplies furnished by an employee of a dentist Member’s condition, benefits will be based
which are normally included in the dentist’s upon the lowest cost alternative. CareFirst
charges and billed by them. benefits will cover treatment based upon the
V. Telephone consultations, failure to keep CareFirst allowance for the less expensive
a scheduled visit, completion of forms or procedure, provided that the less expensive
administrative services. procedure meets accepted standards of
W. Services or supplies that are experimental or professional dental treatment. CareFirst’s
investigational in nature. decision does not commit the Subscriber to
X. Orthodontic or any other services for the less expensive procedure. However, if
cosmetic purposes. the Subscriber and the dentist choose the
Y. Transitional orthodontic appliances, including a more expensive procedure, the Subscriber is
lower lingual holding arch placed where there responsible for the additional charges beyond
is not premature loss of the primary molar. those approved or allowed by CareFirst.
Z. Limited or complete occlusal adjustments in
3.2 Exclusions. Benefits will not be provided for:
connection with periodontal surgical treatment
when received in conjunction with restorative A. Replacement of a denture, bridge or crown as a
service on the same date of service. result of loss or theft.
AA. S
ervices required solely for administrative B. Replacement of an existing denture, bridge or
purposes, for example, employment, insurance, crown that is determined by CareFirst to be
foreign travel, school, camp admissions or satisfactory or repairable.
participation in sports activities.
22 ■ 855-503-4862 ■ carefirst.com/shopdentalC. Replacement of dentures, bridges, implants, P. Any orthodontic services after the last day
metal and/or porcelain crowns, inlays, onlays of the month in which Covered Dental
and crown build-ups within 60 months from Services ended.
the date of placement or replacement for Q. Services or supplies that are not medically
which benefits were paid in whole or in necessary as determined by CareFirst.
part under the terms of the dental benefits R. Services not specifically listed in the dental
Agreement and are judged by CareFirst to be benefits Agreement as a Covered Dental
adequate and functional. Service, even if medically necessary.
D. Treatment or services for temporomandibular S. Services or supplies that are related to an
joint (TMJ) disorders, including but not limited excluded service (even if those services or
to radiographs and/or tomographic surveys. supplies would otherwise be covered services).
E. Gold foil fillings. T. Separate billings for dental care services or
F. Periodontal appliances. supplies furnished by an employee of a dentist
G. Prescription drugs including but not limited which are normally included in the dentist’s
to antibiotics administered by the member, charges and billed by them.
inhalation of nitrous oxide, injected or applied U. Telephone consultations, failure to keep
medications that are not part of the dental a scheduled visit, completion of forms or
service being rendered, and localized delivery administrative services.
of chemotherapeutic agents for the treatment V. Services or supplies that are experimental or
of a medical condition, unless specifically investigational in nature.
listed as a Covered Dental Service in the dental W. Orthodontic or any other services for
benefits Agreement. cosmetic purposes.
H. Nightguards for members over age 19 or other X. Transitional orthodontic appliances, including a
oral orthotic appliances, unless specifically lower lingual holding arch placed where there
listed as a Covered Dental Service in the dental is not premature loss of the primary molar.
benefits Agreement. Y. Limited or complete occlusal adjustments in
I. Bacteriologic studies, histopathologic exams, connection with periodontal surgical treatment
accession of tissue, caries susceptibility when received in conjunction with restorative
tests, diagnostic radiographs and other service on the same date of service.
pathology procedures, unless specifically Z. Provision splinting (intracoronal
listed as a Covered Dental Service in the dental and extracoronal).
benefits Agreement. AA. Endodontic implants.
J. Intentional tooth reimplantation or BB. Fabrication of athletic mouthguards.
transplantation. CC. Services to alter vertical dimension and/
K. Interim prosthetic devices (fixed or removable) or restore or maintain the occlusion. Such
not part of a permanent or restorative procedures include but are not limited to
prosthetic service. equilibration, periodontal splinting, full mouth
L. Additional fees charged for visits by a dentist to rehabilitation and restoration for misalignment
the member’s home, to a hospital, to a nursing of teeth.
home or for office visits after the dentist’s DD. Adjustments to maxillofacial
standard office hours. CareFirst shall provide prosthetic appliance.
the benefits for the dental service as if the visit EE. Maintenance and cleaning of a maxillofacial
was rendered in the dentist’s office during prosthesis (extra or intraoral).
normal office hours. FF. Any orthodontic services after the last day of
M. Transseptal fiberotomy. the calendar year in which the member turned
N. Orthognathic surgery. age 19.
O. The repair or replacement of any orthodontic GG. Services required solely for administrative
appliance, unless specifically listed as purposes, for example, employment,
a Covered Dental Service in the dental insurance, foreign travel, school, camp
benefits Agreement. admissions or participation in sports activities.
Individual BlueDental Preferred 2021 ■ 23For Virginia residents: C. Replacement of dentures, bridges, metal and/
or porcelain crowns, inlays, onlays and crown
3.1 Limitations.
build-ups within 60 months from the date of
A. Covered dental services must be performed placement or replacement for which benefits
by or under the supervision of a dentist with were paid in whole or in part under the
an active and unrestricted license, within terms of the dental benefits Agreement and
the scope of practice for which licensure or are judged by CareFirst to be adequate and
certification has been obtained. functional.
B. Benefits will be limited to standard procedures D. Treatment or services for temporomandibular
and will not be provided for personalized joint (TMJ) disorders including but not limited
restorations or specialized techniques in to radiographs and/or tomographic surveys.
the construction of dentures or bridges, E. Gold foil fillings.
including precision attachments, custom F. Periodontal appliances.
denture teeth and implant supported fixed or G. Prescription drugs including but not limited
removable prostheses. to antibiotics administered by the member,
C. If a member switches from one dentist to inhalation of nitrous oxide (except for
another during a course of treatment, or if members under age 19), injected or applied
more than one dentist renders services for one medications that are not part of the dental
dental procedure, CareFirst shall pay as if only service being rendered, and localized delivery
one dentist rendered the service. of chemotherapeutic agents for the treatment
D. CareFirst will reimburse only after all dental of a medical condition, unless specifically
procedures for the condition being treated listed as a Covered Dental Service in the dental
have been completed (this provision does not benefits Agreement.
apply to orthodontic services). H. Nightguards for members over age 19 or other
E. In the event there are alternative dental oral orthotic appliances, unless specifically
procedures that meet generally accepted listed as a Covered Dental Service in the dental
standards of professional dental care for a benefits Agreement.
Member’s condition, benefits will be based I. Bacteriologic studies, histopathologic exams,
upon the lowest cost alternative. CareFirst accession of tissue, caries susceptibility
benefits will cover treatment based upon the tests, diagnostic radiographs and other
CareFirst allowance for the least expensive pathology procedures, unless specifically
procedure, provided that the least expensive listed as a Covered Dental Service in the dental
procedure meets accepted standards of benefits Agreement.
professional dental treatment. CareFirst’s J. Intentional tooth reimplantation or
decision does not commit the Subscriber to transplantation for members over age 19.
the least expensive procedure. However, if K. Interim prosthetic devices (fixed or removable)
the Subscriber and the dentist choose the not part of a permanent or restorative
more expensive procedure, the Subscriber is prosthetic service.
responsible for the additional charges beyond L. Additional fees charged for visits by a dentist to
those approved or allowed by CareFirst. the member’s home, to a hospital, to a nursing
home or for office visits after the dentist’s
3.2 Exclusions. Benefits will not be provided for:
standard office hours. CareFirst shall provide
A. Replacement of a denture, bridge or crown as a the benefits for the dental service as if the visit
result of loss or theft. was rendered in the dentist’s office during
B. Replacement of an existing denture, bridge or normal office hours.
crown that is determined by CareFirst to be M. Transseptal fiberotomy.
satisfactory or repairable. N. Orthognathic Surgery, unless required to attain
functional capacity for Members up to age 19
until the end of the calendar year in which the
Member turns age 19.
24 ■ 855-503-4862 ■ carefirst.com/shopdentalYou can also read
