Dental Blue Basic
Plan Information

A. Enrollment and Eligibility
You and your enrolling dependents must be permanent, legal residents of the United States. You and your enrolling spouse must be age 64 ¾ or younger.

Eligible dependents include:

  • the subscriber’s lawful spouse
  • any unmarried child (of the subscriber or the enrolled spouse) under age 19
  • any unmarried child (of the subscriber or the enrolled spouse) ages 19 to 23, who qualifies as a dependent for federal income tax purposes
  • the subscriber’s or enrolled spouse’s child, who continues to be both incapable of self-support due to continuing mental retardation or physical handicap, and who is at least one-half dependent on the subscriber or enrolled spouse for support

B. Your Effective Date
Policy effective dates are always the FIRST of the month. If the enrollment form and payment information are received by by the 25th of the month, coverage will become effective on the FIRST of the following month. Incomplete enrollment forms, or failure to submit the required initial premium amount may cause an initial delay in issuance of insurance. Do not cancel any other insurance or assume you are insured under the Policy until you receive your certificate of insurance.

C. How does the plan work?
As long as you meet the plan’s general eligibility requirements and pay the applicable premium, your acceptance is automatic. There are no waiting periods for cleanings, exams and X-rays; a six – month waiting period for all other covered services. This plan pays the cost of exams, cleanings and x-rays.

D. Annual Deductible & Calendar Year Maximums
The annual deductible is the amount of covered dental charges incurred by an insured person or on behalf of your insured dependent before Dental Blue starts paying benefits. The annual deductible of $25 will apply to each insured person. There is no maximum of three deductibles per family per calendar year for this plan.

The deductible is waived for in-network diagnostic and preventive services. The Calendar Year Maximum is the maximum amount the plan will pay for all eligible dental expenses in any calendar year. The Calendar Year Maximum for this policy is $500.

E. Choice of Provider
Dental Blue allows you to choose from over 18,000 dentist locations in our network. Whether you choose a Dental Blue Basic or Dental Blue Enhanced plan , you have the power to visit any dentist or specialist in the Dental Blue 100 network.  You also have the freedom to visit a dentist outside of our Dental Blue network altogether if you want. If you choose to see a dentist who is not part of the dental network,  your claim allowance is based upon a fee schedule.  Keep in mind, however, you will usually save the most money when you visit a dentist within the Dental Blue network you selected.

F. Specialty Care/Specialty Referrals
Specialty Care can be utilized and the benefits will be applied based on the type of service needed, provided the waiting periods have been satisfied.

G. Emergency Dental Services
Except for palliative emergency treatment, there is no specific code tied to emergency services and no special limitation or exclusion for services which are emergency vs. non-emergency.

H. Coordination of Benefits
There is no coordination of benefits for this plan.

I. Cancellation Policy
If you wish to cancel your policy, the cancellation will become effective the first of the month following our receipt of your written notice to cancel or the paid to date, whichever comes first.

J. Termination of Policy
Coverage ceases under the plan when: You do not pay the premium when due, subject to the grace period; the spouse is no longer married to the principal insured; a child fails to meet the previously listed eligibility requirements; any member becomes enrolled in any other Blue Cross of California/BC Life & Health Insurance Company 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 Company of all changes affecting any member’s eligibility.

K. Exclusions/Limitations
Any condition for which benefits are recovered or can be recovered, either by any workers’ compensation law or similar law even if you do not claim those benefits. If there is a dispute or substantial uncertainty as to whether benefits may be recovered for those conditions pursuant to workers’ compensation law or similar law, we will provide the benefits of this plan for such conditions, subject to the right to a lien or other recovery under section 4903 of the California Labor Code or other applicable law.

Any services you actually received that were provided by a local, state, county or federal government agency including any foreign government, except when payment under this Policy is expressly required by federal or state law. This Policy will not cover payment for these services if you are not required to pay for them or they are given to you for free. Veterans Administration Hospitals and Military Treatment Facilities will be considered for payment according to current legislation.

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.

Expenses Before Coverage Begins or After Coverage Ends: Services received before your Effective Date or services received after your coverage ends.

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 (including but not limited to external bleaching, bleaching of non-vital discolored teeth, composite restorations, veneers, crowns on teeth not exhibiting pathology and facings on crowns on posterior teeth). *

Excess Amounts: Any amounts in excess of the dental benefit maximums and yearly Maximum Benefit stated in this Policy. The Covered Expense for all Covered Services includes the administration of any local anesthesia and the provision of infection control procedures as required by state and federal mandates. If billed separately, such charges will be denied. *

Procedures requiring Appliances or restorations (other than those for replacement of structure loss from tooth decay) that are necessary to alter, restore or maintain occlusions. These include but are not limited to:

  • Changing the vertical dimension.
  • Replacing or stabilizing lost tooth structure by attrition, abrasion, abfraction, erosion or bruxism.
  • Realignment of teeth.
  • Gnathological recording.
  • Occlusal equilibration.
  • Periodontal splinting.

Replacement of existing fillings for any purpose other than restoring active decay. The extraction of immature erupting third molars and nonpathologic, asymptomatic third molars is excluded. Third molar extractions are not covered under age 16.

Charges for tobacco counseling, oral hygiene instruction, dietary planning, or behavior management.

Diagnosis or Treatment of the Joint of the Jaw and/or Occlusion: Services, supplies or appliances provided in connection with 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 Treatment of congenital or developmental malformations including but not limited to cleft palate, maxillary and mandibular malformations, enamel hypoplasia, fluorosis, and anodontia.

Implants: Materials implanted into or on bone or soft tissue and all adjunctive services (including but not limited to surgery, prosthetics placed on implants, cleanings, maintenance, etc.) performed in conjunction with the placement or removal of implants.*

All hospital costs and any additional fees charged by the Dentist for hospital treatment.

Services or treatments that are not Medically Necessary. Medically necessary services or treatments are those which are ordered by the attending Dentist for the direct care and treatment of a covered condition. They must be standard dental practice where received for the condition being treated and must be legal in the United States.

Orthodontic services, cephalometric film, braces, appliances and all related services including surgery necessary in conjunction with orthodontic treatment.

Transfer of care: If a Policyholder 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.

Services for treatment of malignancies and neoplasms. Complications of Non-Covered Services:

Services not specifically listed in the “Benefit Schedule” section of the Policy.*

Charges for treatment by other than a licensed Dentist, except charges for dental prophylaxis performed by a licensed dental hygienist.

Oral evaluations exceeding two visits per Year.

Prophylaxis (teeth cleaning) exceeding two per Year.

More than one set of full-mouth X-rays or its equivalent in a five (5) year period.

Fluoride applications:

  • if you are over eighteen (18) years of age
  • exceeding two per Year

Periapical and bitewing X-rays submitted singly will be combined and paid up to the amount of a full mouth series and are subject to the full-mouth X-ray limitation. No more than one (1) bitewing X-ray series in a Year will be covered. No more than eight (8) films for vertical bitewings in a 60 month period will be covered.

Fillings exceeding one per Year per surface per tooth if you are under the age of 19 and one every three (3) years per surface per tooth if you are age 19 and older.

If a tooth or teeth can be restored with amalgam (with the exception of composite resin on anterior teeth), any amount exceeding the cost of that material is not covered if another material is used. Anterior teeth exhibiting pathology eligible for composite restorations are central incisors, lateral incisors, cuspids and the facial surface of bicuspids.

Services for oral surgery, for example, tooth extractions.

Services for endodontics, for example, root canals. Endodontics means the branch of dentistry dealing with diseases of the tooth pulp.

Services for periodontics, for example, scaling and root planing. Periodontics is the dental specialty of treating periodontal disease.

Services for prosthodontics, for example, crowns. Prosthodontics is the branch of dentistry dealing with the construction of artificial appliances for the mouth, especially for the purpose of replacing missing teeth with bridges and dentures.

* Even though these services are not covered as part of the dental plan, discounted fees for these services are available from in-network dentists.

L. Grievance Procedures
If you have a complaint about services from BC Life or your health care provider, please call us first toll free at (888) 209-7852 or write to us at:

BC Life & Health Insurance Company
P.O. Box 9066
Oxnard, California 93031-9066

M. Disclaimer
This is a general group summary of the features of this plan. When you purchase the plan you will receive a Certificate of Insurance that details your rights and obligations, as well as those of the insurance company.

This website provides a very brief description of some of the important features of this plan. It is not the insurance contract, nor does it represent the insurance contract. A full description of benefits, exceptions and limitations is contained in the Certificate of Insurance.

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