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 theyturnage26,regardlessoftheirfinancialdependency,studentstatus,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 ThisdentalplanincludesanAccumulatedMaximumRolloverBenefit.Thisrollover benefitallowsyoutorolloveracertaindollaramountofyourunusedannualdental benefitsforuseinthefuture.Therearelimitsandrestrictionsonthisbenefit.Refer to the Accumulated Dental Maximum Rollover brochure for further information. Enhanced Dental Benefits EnhancedDentalBenefitsforcertaindentalcareservicesareavailablefor members who have been diagnosed with qualifying conditions. To learn more aboutspecificconditionsincludedinthisbenefit,reviewyourplandescription (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. Afteryourdentistfillsouttheform,senditandyouroriginalitemizedbillsto 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. Ifyouhaveagrievance,seeyourplandescriptionforinstructionsonhowtofile a grievance. Other Information Coordinationofbenefitsappliestoplanmemberswhoarecoveredbyanother planforhealthcareexpenses.Coordinationofbenefitsensuresthatpayments 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. LimitationsandExclusions.Thesepagessummarizethebenefitsofyourdentalplan.Yourplandescriptionandridersdefinethefulltermsandconditionsingreaterdetail.Shouldanyquestionsarise concerningbenefits,theplandescriptionandriderswillgovern.Foracompletelistoflimitationsandexclusions,refertoyourplandescriptionandriders. ® 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