PPO Prudent Buyer Dental Plan 

How The Plan Works
Who Is Eligible
What Are The Plan Benefits
How Much Does The Plan Cost 
What Benefits Are Excluded
Print and Complete The Application

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BC Life & Health Insurance Company has Created the Prudent Buyer Dental Plan, a Preferred Provider Organization dental plan, to keep your teeth healthy and your smile bright. The hundreds of dedicated professionals who comprise the Prudent Buyer Services including routine check-ups, cleanings, fillings, crowns and dental surgery.
The Prudent Buyer Dental Plan was designed with two goals in mind. The first and foremost is to promote good dental hygiene and preventive care, recognized as important elements is total health care package. The second goal is to provide you with the dental care you need in a convenient, cost-conscious manner, thus providing many dental services at reduced or no out-of-pocket cost.
The Plan features Preventive and Diagnostic Care at little or no cost, low cost Basic Care, and a benefit schedule that can help you offset the high cost of Major Care dental work.  Please read the following information for details on how the plan works, specific benefit information and certain exclusions and limitations that apply.
 How the Prudent Dental Plan Works
The Prudent Buyer Dental Plan Network is made up of a large number of dentists in California who have agreed to provide services at negotiated rates to Prudent Buyer Plan Members. When you Choose a Participating Plan Dentist, you pay nothing for Preventive and Diagnostic Care, Such as regular check-up, cleanings and X-rays. Other benefits are provided for specified basic and major dental care.
The Plan lets you know up front in flat dollar amounts how much the plan pays for the covered services. This means that you are able to calculate easily how much you will have to pay once you have determined your dentist's fee for the specific procedures listed.
It is your benefit to use a Participating Plan dentist because Blue Cross of California and BC Life & Health Insurance Company have negotiated the amounts that Prudent Buyer Plan members are charged for services. You may choose a non-Participating dentist, and the Plan still provides benefits, but your out-of-pocket expense may be greater as the negotiated fees do not apply to non- Participating providers. You are responsible for any charges in excess of the stated benefit.
The Participating Plan Network is large, and your current dentist already may be part on the Network. So be sure to check the Prudent Buyer Plan Dental directory before you choose a dentist. It could save you money.
Calendar Year Deductible is he amount of out-of-pocket expense for which you are responsible before your benefits are available. The Calendar Year Deductible is $50 per person, with a maximum of 3 calendar year deductibles per family (total $150). The deductible is waived for the Preventive and Diagnostic Care only at Participating Plan dentists.
 Calendar Year Maximum Benefit: All dental benefits are limited to a maximum payment by BC Life & Health of $1,000 for expenses incurred by each enrolled member during a calendar year.
Waiting Periods: There is no waiting period for Preventive and Diagnostic Care. Coverage for Basic Care begins after three continuous months and for Major Care after twelve continuous months of coverage.
Customer Service: BC Life & Health Insurance Company's professional Dedicated Enrollment Units are available to answer any questions you may have about your Policy, and to assist you in your customer service needs. The toll-free number is listed on your Prudent Buyer Dental Plan identification card that you will receive once your enrollment is approved.
Benefit Schedules
Coverage is provided only for the services services below.
To use the following schedules, first determine your dentist's fee, then look up how much the plan pays. Then you can calculate easily how much you will have to pay for the specific services after your deductible has been met (where applicable. The dollar amounts are maximums. The Plan pays either the specified amount, or the actual amount charged by your dentist, whichever is lower. You are responsible for any charges in excess of the stated benefit.
Preventive & Diagnostic Care
Coverage begins upon approval of your application.  You are limited to two oral examinations and two dental cleanings per member, per year. The calendar year deductible is waived for these services only when rendered by a Participating Plan dentist.
At a Participating dentist At a Non-Participating dentist
The Plan Pays The Plan Pays
Procedure
Initial Oral exam 100% $25
Periodic Oral Exam
      Limited to 2 per member per year		 100%
 $18
Emergency Oral Exam 100% $28
Bitewing X-rays - single film 100% $16
Bitewing X-rays - two film 100% $18
Single (periapical) X-rays - first film
     Single X-rays - additional films		 100%
100%		 $13
$8
Bitewing X-rays - four films 100% $26
Full mouth X-rays
      limited to one set every 3 years		 100%
 $60
Routine cleaning
      limited to 2 per adult per year		 100%
 $39
Routine cleaning
      limited to 2 per child per year		 100%
 $30
Cleaning with fluoride
     limited to 2 per child per year		 100%
 $35
Tropical fluoride only
      limited to 2 per child per year		 100%
 $14
* Total benefit for single and bitewing X-rays not to exceed cost of full mouth-$60 an non-Participating dentists
Basic & Major Dental Care
After the calendar year deductible has been satisfied, benefits are paid according to the following schedules. Although the schedule is the same for both Participating and non-Participating providers, you may experience greater out-of-pocket expense at a non-Participating provider. 
Basic Dental Care
Coverage begins after the policy has been in effect for three continuous months.
Procedure Plan Pays
Filling - one surface, primary $ 38
Filling - one surface, permanent $ 42
Filling - two surface, primary $ 49
Filling - two surface, permanent $ 55
Filling - three surface, primary $ 60
Filling - three surface, permanent $ 72
Filling - four or more surface, primary $ 70
Filling - four or more surface, permanent $ 84
Extraction - single tooth (simple) $ 49
Extraction - each additional tooth (simple) $ 46
Surgical extraction $ 84
Removal of impacted tooth - soft tissue $ 111
Removal of impacted tooth - partial bony $ 148
Removal of impacted tooth - complete bony $ 180
Note:
Adult- Any person or dependent 19 years or older covered by this Policy.
Child- Any person or dependent 18 years or younger covered by this Policy.
Major Dental Care
Coverage begins after the policy has been in effect for twelve continuous months.
Procedure

Plan Pays
Scaling/root planing per quadrant $48
Gingivectomy - per tooth $40
Gingivectomy - per quadrant $145
Osseous surgery per quadrant
              paid at $70 per tooth to a maximum of $277/quadrant		 $277
Root Canal - 1 canal $154
Root Canal - 2 canal $189
Root Canal - 3 canal $242
Inlay - one surface $172
Inlay - two surface $198
Inlay - three surface $220
Onlay - in addition to inlay $57
Crown (except stainless steel) $264
Stainless steel crown $57
Pontic $264
Post & core - in addition to crown $75
Complete denture (upper or lower) $343
Partial denture (upper or lower) $308
Denture reline (Chairside) $75
Denture reline (lab) $106
Eligibility & Enrollment
Who is eligible for coverage?
  • You, the principal insured, if under age 64
  • Your spouse in under age 64
  • You or your enrolled spouse's unmarried children under 19 years of age
  • You or your enrolled spouse's unmarried children between the ages of 19 through 22 who are defined as
    dependent by IRS regulations
  • Any un married children of you or your enrolled spouse between the ages of 19 through 22 who continue to be dependent upon you for at least half of their support
Date Coverage Begins
The effective date of your Prudent Buyer Dental Plan is assigned by BC Life & Health Insurance Company and will be the first of the month after approval.
Premium Rates For Orange County
The rates listed are monthly rates. Monthly payment is available only in tandem with Monthly Checking Account Deduction billing. If you wish to pay Bi-monthly, Multiply by two; if you prefer to pay quarterly, multiply by three.
 

Contract Type

Age  Band Monthly Premiums
Subscriber Only 19-64 $38
Subscriber & Spouse 19-64 $74
Subscriber & Child 19-64 $59
Subscriber & Children 19-64  $92
Family 19-64 $118
1 Child 0-18 $31
2 Children 0-18 $59
3+Children 0-18 $84

To Apply Now (Click Here)
Call Our Ofice For Rates In Other Counties.
Coverage ceases under the Prudent Buyer PPO Dental Plan when:  You do not pay the premium when due, subject to the grace period; upon the first of the month in which any covered member attains age 65; any member becomes eligible for Medicare coverage even if no application for Medicare coverage is made; any members eligible for Medicare coverage even if no application for Medicare coverage is made; the spouse is no longer married to the principal insured; the child fails to meet previously listed eligibility requirements; any member becomes enrolled in any other Blue Cross non-group coverage; any covered member resides in a foreign country for more than six consecutive months or is absent from California for more than six consecutive months.  You must notify BC Life & Health Insurance of all changes affecting any member’s eligibility.
Non-Duplication of Blue Cross Benefits
If, while covered under this Policy, the member is covered by another Blue Cross of California/BC life & Health Individual policy, he or she will be entitled only to the benefits of the policy with greater benefits.  The Blue Cross Companies will refund any premium received under the policy with the lesser benefits, covering the time both policies were in effect.  However, any claims payments made by the Blue Cross Companies under the policy with the lesser benefits will be deducted from any such refund of premium.
Arbitration
Any dispute between you and Blue Cross of California and/or its affiliates must be resolved by binding arbitration if the amount in dispute exceeds the jurisdictional limits of the Small Claims Court.  Any such dispute will be resolved not by law or resort to court process, except as California law provides for judicial review of arbitration proceedings.  Under this coverage, both you and Blue Cross of California and its affiliates are giving up the right to have any dispute decided in a court of law before a jury.
Exclusions and Limitations
We will not furnish benefits for:
Unlisted Services:  Services not specifically listed in this Policy.
Excess Amounts:  Any amounts in excess of the maximum amounts stated in the “Benefit Schedule” section.
Expense Before Coverage Begins:  Services received before your Effective Date or during an inpatient stay that began before your effective Date.
End of Coverage Begins:  Services received after your coverage ends.
Services For Which You Are Not Legally Obligated To Pay:  Services for which no charge is made to you in the absence of insurance coverage.
Worker’s Compensation:  Any condition for which benefits are recovered or can be recovered, either by adjudication, settlement or otherwise, under any workers’ compensation, employer’s liability law or occupational disease law, even if you do not claim those benefits.
War:  Disease contracted or injuries sustained as a result of war declared or undeclared, conditions caused by the inadvertent release of nuclear energy when government funds are available for treatment of illness or injury arising from such release of nuclear energy.
Government Services:  Any services provided by a local, state, county or federal government agency including any foreign government.
Services from Relatives:  Professional services received from a person who lives in the Insured’s home or who is related to the Insured by blood, marriage or adoption.
Cosmetic Dentistry:  Any services performed for cosmetic purposes are not covered under this Policy, unless they are for correction of functional disorders or as a result of an accidental injury occurring while you were covered under this Policy.
Charges for treatment by other than a licensed dentist or physician, except charges for dental prophylaxis performed by a licensed dental hygienist, under the supervision and direction of a dentist.
Replacement of an existing prosthesis which has been lost or stolen; or which in the opinion of the dentist is or can be made satisfactory.
Replacement of a fixed or removable prosthesis for which benefits were paid by BC Life & Health, if such replacement occurs with in five years of the original placement, unless the denture is a stayplate used during the healing period for recently extracted anterior teeth.
Orthodontic services, braces, appliances and all related services.

Diagnosis or Treatment of the Joint of the Jaw and/or Occlusion (the way upper and lower teeth meet) services, supplies or appliances provided in connection with:

  1. Any treatment to alter, correct, fix, improve, remove, replace, reposition, restore or otherwise treat the joint of the jaw (temporomandibular joint) or associated musculature, nerves and other tissues for any reason or by any means; or
  2. Any treatment, including crown, caps and/or bridges to change the way the upper and lower teeth meet (occlusion0; or
  3. Treatment to change vertical dimension (the space between the upper and lower jaw) for any reason. Or by any means including the restoration of vertical dimension because teeth have worn down.

 
Correction of congenital or developmental malformation for a Principal Insured or Dependent Insured including but not limited to cleft palate, maxillary or mandibular (upper and lower jaw) malformations, enamel hypoplasia (lack of development), fluorosis a type of discoloration of the teeth), and anodontia (congenitally missing teeth).
Adjustment, repairs or relines to prostheses for a period of six months from initial placement if the prostheses were paid for under this Policy.
Fixed bridges, removable cast partials and/or cast crowns with or without veneers and inlays for patients under sixteen years of age.
Replacement of crowns and cast restorations including porcelain inlays and porcelain crowns for which benefits were paid by BC Life & Health, if such replacement occurs within five years of the original placement.
Transfer of care:  If a Principal Insured transfers from the care of one dentist to that of another dentist during the course of treatment, or if more than one dentist renders services for one dental procedure, BC Life & Health shall be liable only for the amount it would have been liable for had one dentist rendered the services.

Prescribed drugs, pre-medication or analgesia. Malignancies and Neoplasms:  Services for treatment of malignancies and neoplasms are not covered Dental Benefits.

All hospital costs and any additional fees charged by the dentist for hospital treatment. Services or Supplies That Are Not Medically Necessary.
Replacement of teeth missing prior to the effective date of coverage with partial dentures, complete dentures, or fixed bridges.
How to enroll
If you are a new member and want dental ONLY:
·        Compete and sign the attached application
·        Determine your premium (see page 7) and your payment plan (see below)
·        Write a check payable to Blue Cross of California
·        Send the application and payment to your agent

For those applying for Blue Cross medical coverage and dental coverage:

  • See instructions in the Individual Enrollment Application

For Blue Cross members who want to ADD dental:

·        Complete the attached application

·        Determine your premium (see page 7) – It should be the same type of billing as you medical coverage.  Even if you are on Monthly Checking Account Deduction, you must send the first month’s premium with the application.

·        Write a check payable to Blue Cross of California

 

To determine your initial premium*:

·        If you want to pay your bill monthly, fill out the attached account deduction form and submit it along with a check for one month’s premium and a blanc check marked “VOID”

·        If you want to pay your bill every other month, write a check for two months’ premium

·        If you want to pay your bill every three months, write a check for three months’ premium

 
 Download & Print Application


Send your application and payment to:  

Chadwick Insurance Agency
27721 Cummins Drive 
Laguna Niguel, CA 92677


When your enrollment is approved you will receive a Prudent Buyer Plan Dental Policy.  Please review it carefully, as it contains specific details about your benefits, coverage, exclusions and limitations.
     *  If you are a Blue Cross member you must select the same payment plan as your health plan.