Welcome to Dental Blue freedom, A DENTAL PLAN DESIGNED TO MANAGE THE COST OF DENTAL SERVICES. Your Dentist How Network Dentists Are Paid - Preferred Dentists Dental Blue Freedom offers a large network of dentists, including dentists in You will receive the greatest value if you visit a preferred dentist, because you will Massachusetts and Rhode Island who participate with Blue Cross Blue Shield maximizetheamountofbenefitsreceivedunderyourplan. of Massachusetts. Dental Blue Freedom members also have access to participating dentists nationwide. When searching for a network dentist, Dental Payments are calculated based on the provisions of the Blue Cross Blue Shield Blue Freedom members can choose from the Dental Blue PPO (Preferred Dentist) preferred dentist’s payment agreement and the dentist’s allowed charge that is in or Dental Blue (Participating Dentist) networks. Using a network dentist will effect at the time the covered dental service is provided. Preferred dentists agree minimize your out-of-pocket expenses. to accept the allowed charge as payment in full. You pay your deductible and coinsurance (if applicable), and any allowed charges beyond your calendar-year If you would like help choosing a dentist, or already have a dentist and want orlifetimebenefitmaximum. to know if they participate with your plan, you can call the dentist, look at the current dental provider directory, or call Member Service at the toll-free phone How Network Dentists Are Paid - Participating Dentists number shown on your Dental Blue ID card. You can also access the online dental For dentists who participate with Blue Cross Blue Shield, but do not have a provider directory at bluecrossma.org. BlueCrossBlueShieldpreferredprovidercontract,benefitsarecalculatedbased on the provisions of the participating dentist’s payment agreement and the Your Benefits dentist’s allowed charge. These dentists agree to accept the allowed charge as You will receive the greatest value if you visit a preferred dentist, because you will payment in full. You pay your deductible and coinsurance (if applicable), and any maximizetheamountofbenefitsreceivedunderyourplan. allowedchargesbeyondyourcalendar-yearorlifetimebenefitmaximum. Thedentalbenefitsyourplancoversaresubjecttothecalendar-yeardeductible How Out-of-Network Dentists Are Paid - Non-Preferred or andcoinsurance(ifapplicable),andbenefitmaximumamountsshowninthe Non-Participating Dentists chart. The calendar year begins on January 1 and ends on December 31 of each Benefitsforcoveredservicesbyanon-preferredornon-participatingdentistare year. The chart also shows the percentage of costs your plan will pay for covered provided based on the allowed charge or the dentist’s actual charge, whichever dentalservices.Manyofthecoveredserviceshavespecifictimeoragelimits. is less. The allowed charge is based on a schedule of charges. You may be responsible for any difference between the dentist’s actual charge or the allowed Pre-Treatment Estimates charge, whichever is less. You are also responsible for your deductible and If your dentist expects that your dental treatment will involve covered services coinsurance (if applicable), and charges beyond your calendar-year or lifetime that will cost more than $250, Blue Cross Blue Shield recommends that your benefitmaximum. dentist send a copy of the “treatment plan” to Blue Cross Blue Shield before services are provided. A treatment plan is a detailed description of the Orthodontic Benefits procedures that the dentist plans to perform and includes an estimate of the Yourplanincludesorthodonticcoverage.Thelifetimebenefitmaximumisnot charge for each service. Once the treatment plan is reviewed, you and your partofyourcalendar-yearbenefitmaximum;itappliesonlytoorthodontic dentistwillbenotifiedofthebenefitsavailable. services. You are responsible for your coinsurance (if applicable) and any charges beyondyourlifetimebenefitmaximum.Benefitsareavailableonyoureffective Remember, the payment estimate is based on your eligibility status and the date. If your orthodontic treatment began before you were covered under Dental amountofyourcalendar-yearorlifetimebenefitmaximumatthetimethe Blue Freedom, a monthly fee will be paid for your remaining orthodontic visits estimate is received and reviewed. (The actual payment may differ if your untileitheryourtreatmentiscompletedorthelifetimebenefitmaximumis availablecalendar-yearorlifetimebenefitmaximumoreligibilitystatus exhausted,whichevercomesfirst. has changed.) Multi-Stage Procedures Yourdentalplanprovidesbenefitsformulti-stageprocedures(proceduresthat require more than one visit, such as crowns, dentures and root canals) as long as you are enrolled in the plan on the date that the multi-stage procedure is completed. A participating dentist will send a claim for a multi-stage procedure to Blue Cross Blue Shield only after the completion date of the procedure. You will be responsible for all charges for multi-stage procedures if your plan has been cancelled before the completion date of the procedure.