Page 12 - 2019 CareHere Enrollment Guide

2019 BENEFITS ENROLLMENT

Dental coverage DENTAL
is provided Dental benefits are available for all regular full-time and regular part-time
by BlueCross employees actively working 20 hours or more per week.

BlueShield of
Tennessee. Dental Benefits

We partner with BlueCross BlueShield of Tennessee to offer you and your
eligible dependents dental insurance. Visit www.bcbst.com to find in-network
providers and access a variety of online tools and programs.

Dental Benefits At-a-Glance

BCBST DentalBlue BCBST DentalBlue
Plan 1—Base Plan 2—With
Orthodontia
In- and Out-of-
Network* In- and Out-of-Network*
Deductible Individual: $50 Individual: $50
Family: $150 Family: $150
Annual Maximum $1,500 $1,500
Preventive Care Covered at 100% Covered at 100%
Basic Care Covered at 80%, after Covered at 80%, after
deductible deductible
Major Care Covered at 50%, after Covered at 50%, after
deductible deductible
Orthodontia
Coinsurance Not covered Covered at 50%, after
deductible
Lifetime Maximum Not covered $1,500
Benefit Applies To N/A Children to age 19

* Services received from non-Preferred Dental Care providers are reimbursed at the
maximum allowable charge and you may be balance billed by the non-participating
dentist.

Dental Bi-Weekly Pre-Tax Contributions
(Full-Time and Part-Time Employees)

Plan 2
Plan 1 (Child Orthodontia)
Employee Only $14.63 $14.70
Employee + Spouse $34.64 $37.66
Employee + Child(ren) $28.33 $30.81
Family $51.64 $56.15

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