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| This is a partial list of services that are not covered by DentalBlue® for Individuals. Your coverage may be canceled by Blue Cross and Blue Shield of North Carolina® for failure to pay premiums when due and for fraudulent statements on your application, among other reasons. Members will be notified 30 days in advance of any change in coverage. Consult your member guide for complete information. Your dental benefits plan does not cover services, supplies, drugs or charges that are: |
| • | Orthodontic services | ||
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Not clinically necessary | ||
| • | Investigational in nature or obsolete, including any service, drugs, procedure or treatment directly related to an investigational treatment | ||
| • | Not prescribed or performed by or upon the direction of a dentist or other provider | ||
| • | Received prior to the member's effective date | ||
| • | Received on or after the coverage termination date, regardless of when the treated condition occurred or whether the care is a continuation of care received prior to the termination | ||
| • | For telephone consultations, failure to keep a scheduled visit, completion of a claim form, obtaining dental records, and late payments. | ||
| • | Incurred more than 18 months prior to submission of a claim to BCBSNC® | ||
| • | For complications or side effects arising from services, procedures, or treatments excluded coverage under the dental benefits plan | ||
| • | Provided and billed by a licensed dental care professional who is in training. | ||
| • | Available to a member without charge | ||
| • | For care given to a member by a provider who is in the member's immediate family | ||
| • | In excess of the allowed amount.8 | ||
| • | Cosmetic services | ||
| • | For dental implants, oral orthotic devices and palatal expanders, except as specifically covered by your dental benefits plan. | ||
| • | Dental services provided in a hospital, except when a hazardous condition exists at the same time, or if covered oral surgery services are required at the same time as a result of a bodily injury. | ||
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Take Control Of Your Dental Care |
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Traditional insurance with |
High Deductible, Tax |
Affordable coverage |
For beneficiaries enrolled |
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| *BCBSNC® internal data, 2006 |
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Triangle Planning Services, Inc. is an independent authorized producer/agency licensed to sell and promote products from Blue Cross |
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FOOTNOTES: |
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| 8: | Allowed amount is 85th percentile of the HIAA (Health Insurance Association of America) index. |