® Dental Blue Accumulated Maximum Rollover At Blue Cross Blue Shield of Massachusetts, we know that oral health is a critical part of overall health. That’s why we offer a dental benefit that will allow you to roll over a portion of your unused dental benefits from year to year. How Maximum Rollover Works Beginning 60 days after the last day of your benefit period, doesn’t pay out more claims dollars on your behalf than the your rollover amount will be added to your maximum benefit amount in the second column, your benefit maximum for the amount, increasing it for you to use that year and beyond next year will increase by the amount in the third column. (see below for amounts and maximums). And, your rollover amount keeps growing and is available There is no cost to you. You don’t need to do anything. for you to use as long as your employer offers this rollover To figure out the amount of benefit dollars that are eligible benefit.* The last column will show you the total amount of to roll over, just use the chart below. Start by searching for additional benefit dollars you can earn. It’s one more way we’re your benefit period maximum in the first column. If Blue Cross working to improve health care for all our members. You can accumulate benefit dollars to help offset higher out-of-pocket costs for complex procedures. This benefit applies to you automatically if: • You receive at least one service during the benefit period • You don’t exceed the claim payment threshold in the • You remain a member of the plan throughout the benefit period benefit period If your dental plan’s And if your total claims We’ll roll over this However, rollover totals will annual maximum benefit don’t exceed this amount amount for you to use be capped at this amount:* amount is: for the benefit period:* next year and beyond:* $500–$749 $200 $150 $500 $750–$999 $300 $200 $500 $1,000–$1,249 $500 $350 $1,000 $1,250–$1,499 $600 $450 $1,250 $1,500–$1,999 $700 $500 $1,250 $2,000–$2,499 $800 $600 $1,500 $2,500–$2,999 $900 $700 $1,500 $3,000 or more $1,000 $750 $1,500 *This is not a flexible spending account (FSA). The amount reflects your benefit maximum for a given year. Blue Cross Blue Shield of Massachusetts complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, or gender identity. ATTENTION: If you don’t speak English, language assistance services, free of charge, are available to you. Call Member Service at the number on your ID card (TTY: 711). ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia con el idioma. Llame al número de Servicio al Cliente que figura en su tarjeta de identificación (TTY: 711). ATENÇÃO: Se fala português, são-lhe disponibilizados gratuitamente serviços de assistência de idiomas. Telefone para os Serviços aos Membros, através do número no seu cartão ID (TTY: 711). Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association. ® Registered Marks of the Blue Cross and Blue Shield Association. 000668960 50-0010 (12/20) ®´ Registered Marks and TM Trademarks are the property of their respective owners. © 2020 Blue Cross and Blue Shield of Massachusetts, Inc., or Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc.