Page 9 - Evisions Benefit Guide 2020 - Effective 1.1.2020

Benefits

Dental Insurance

Blue Shield | PPO Dental Plan
With the Blue Shield Preferred Provider Organization (PPO) dental plan, you may visit a PPO dentist and benefit from the
negotiated rate or visit a non‐network dentist. When you utilize a PPO dentist, your out-of-pocket expenses will be less. You may
also obtain services using a non-network dentist; however, you will be responsible for the difference between the covered amount
and the actual charges and you may be responsible for filing claims.

Blue Shield
Plan Name PPO
Network Name Dental PPO - Smile Spectrum Premier Non-Network
Dental Benefits

Calendar Year Maximum $1,500 $1,500
Deductible (Annual)
- Individual $50 $50
- Family $150 $150
Preventive (Plan Pays) 100% 100%
Exams, X-Rays, Cleanings
Basic Services (Plan Pays) Deductible, 80% Deductible, 80%
Fillings, Oral Surgery, Endodontics, Periodontics
Major Services (Plan Pays) Deductible, 50% Deductible, 50%
Crowns, Prosthetics

Orthodontia
- Covered Members Children & Adults
- Coinsurance 50%
- Lifetime Benefit Maximum $1,000

Finding a Dental Provider
Go to www.blueshieldca.com or call (888) 702-4171. PPO participants should refer to the “Dental PPO - Smile
Spectrum Premier” network when prompted.

Tips for Using Your Dental Benefits

Understand your plan.
Understanding your dental plan’s benefits, including how copays, deductibles, and calendar year maximum benefits work, is key to
getting the most value from your plan and avoiding surprises.

Ask for a predetermination of benefits.
We strongly recommend you ask your dentist for a predetermination if total charges are expected to exceed $300.
Predetermination enables you and your dentist to know in advance what the payment will be for any service that may be in
question.

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