When Coverage Begins You are covered, without a waiting period, from the date you enroll in the plan. Dependent Benefits This plan covers dependents until the end of the calendar month in which they  turn  age  26,  regardless  of  their  financial  dependency,  student  status,  or  employment status. See your plan description (and riders, if any) for exact coverage details. Domestic Partner Coverage Domestic partner coverage may be available for eligible dependents. Contact your plan sponsor for more information. Accumulated Maximum Rollover Benefits This  dental  plan  includes  an  Accumulated  Maximum  Rollover  Benefit.  This  rollover  benefit  allows  you  to  roll  over  a  certain  dollar  amount  of  your  unused  annual  dental  benefits  for  use  in  the  future.  There  are  limits  and  restrictions  on  this  benefit.  Refer  to the Accumulated Dental Maximum Rollover brochure for further information. Enhanced Dental Benefits Enhanced  Dental  Benefits  for  certain  dental  care  services  are  available  for  members who have been diagnosed with qualifying conditions. To learn more about  specific  conditions  included  in  this  benefit,  review  your  plan  description  (and riders, if any) on MyBlue at bluecrossma.org . If You Have to File a Claim Network dentists will send claims directly to Blue Cross Blue Shield. All you have to do is show them your Dental Blue ID card. The payment will be sent directly to your dentist as long as the claims are received within one year of the completed service. If you receive care from an out-of-network dentist, you will typically need to submit the claim yourself. Before submitting your claim, get an Attending Dentist’s Statement form from Member Service. After  your  dentist  fills  out  the  form,  send  it  and  your  original  itemized  bills  to  Blue Cross Blue Shield of Massachusetts, P. O. Box 986030, Boston, MA 02298. All member-submitted claims must be submitted within two years of the date of service. If  you  have  a  grievance,  see  your  plan  description  for  instructions  on  how  to  file  a grievance. Other Information Coordination  of  benefits  applies  to  plan  members  who  are  covered  by  another  plan  for  health  care  expenses.  Coordination  of  benefits  ensures  that  payments  from other insurance or health care plans do not exceed the total charges billed for covered services. Your plan description has a subrogation clause, which means that Blue Cross Blue Shield can recover payments if a member has already been paid for the same claim by a third party. Questions? For questions about Blue Cross Blue Shield of Massachusetts, call 1-800-782-3675, or visit us online at bluecrossma.org. Limitations  and  Exclusions.  These  pages  summarize  the  benefits  of  your  dental  plan.  Your  plan  description  and  riders  define  the  full  terms  and  conditions  in  greater  detail.  Should  any  questions  arise  concerning  benefits,  the  plan  description  and  riders  will  govern.  For  a  complete  list  of  limitations  and  exclusions,  refer  to  your  plan  description  and  riders.  ® Registered Marks of the Blue Cross and Blue Shield Association. © 2023 Blue Cross and Blue Shield of Massachusetts, Inc. Printed at Blue Cross and Blue Shield of Massachusetts, Inc. April 2025