2023 DENTAL INSURANCE PLANS - F OR YOU A ND YOUR FA MILY
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2023 DENTAL INSURANCE PLANS
F O R Y O U A N D Y O U R F A M I LY
22D-ABCBS-0799 MPI 8598.5 09/22 DR
DENTAL
Arkansas Blue Cross and Blue Shield
offers affordable dental insurance plans
for individuals and families. From essential
preventive care to restorative services, our
plans provide flexible options for staying
healthy and within your budget.
We make it easy to find a dentist or see the
one you already have — 95% of dentists in
Arkansas are in our provider network.*
*Percentage of licensed dentists in Arkansas contracted
in our PPO Plus network.
+
DENTAL + VISION
Our combo plans include all the benefits
of our dental insurance plans plus vision
benefits such as low copayments for eye
exams and coverage for glasses or contacts.
2
Dental Xtra
SM
Keeping your mouth healthy has a big impact on your overall health, especially if
you have certain medical conditions. Through the Dental Xtra program, members
with qualifying conditions get additional benefits that can help improve total health.
Dental Xtra benefits are covered 100% when you see a participating provider —
there are no additional out-of-pocket expenses and they don’t apply toward your
calendar year maximum.
You’re automatically enrolled if you have medical and dental plans with Arkansas
Blue Cross and a qualifying medical condition. If you’re pregnant or don’t have an
Arkansas Blue Cross medical plan, you can easily self-enroll online.
Dental Xtra benefits provided to qualifying members at no extra cost:
Two additional cleanings or
periodontal maintenance visits,2 plus:
Dental Xtra Scaling covered Cancer screenings;
Eligible medical conditions 100%2 fluoride treatments
Chronic obstructive pulmonary disease1
Coronary artery disease
Diabetes
End-stage renal disease1
Metabolic syndrome1
Oral, head and neck cancers
Pregnancy
Sjögren’s syndrome
Stroke
1
Starting Jan. 1, 2023.
2
See your policy for details about included services.
Calendar Year Rollover Here’s how it works:
Gold and Platinum members 19 years of age or older
can take advantage of our Calendar Year Rollover GOLD PLATINUM
program, which allows you to save some of your
unused benefit dollars to use in future years. With Yearly threshold amount $500 $700
this feature, you may roll over $350 for Gold plans
and $500 for Platinum plans to the next calendar year. Amount you can roll over to
$350 $500
next year
Over time, you can reach up to $2,000 in annual
benefits if you have a Gold plan, or up to $2,750 Maximum accumulated
$1,000 $1,250
if you have a Platinum plan. rollover
3
Dental Plans PEDIATRIC
Child Only
(Age 0-18)
Child
(Age 0-18)
SILVER
Adult
(Age 19+)
Plan year maximum Unlimited Unlimited $1,000
$375 for one child;
Out-of-pocket maximum $375 $750 for two or Unlimited
more children
6 months3
Waiting periods3 None None
(minor restorative)
Rollover benefit None None
Dental Xtra benefit Yes Yes
CALENDAR YEAR BENEFITS MEMBER PAYS (IN NETWORK)
Deductible $20 $50
Diagnostic and preventive coverage
Exams, prophylaxis (teeth cleaning), X-rays 0% coinsurance
10% coinsurance after deductible
(pediatric plan also covers fluoride treatment after deductible
and sealants)
Minor restorative coverage
Fillings, endodontics (root canals), 20% coinsurance 30% coinsurance 25% coinsurance
oral surgery, extractions, periodontics after deductible after deductible after deductible
(treatment for gum disease)
Major restorative coverage 50% coinsurance
• All ages — crowns, partials and 50% coinsurance 50% coinsurance (re-cementations,
dentures, surgical periodontics after deductible after deductible repairs and
• 19 and over — bridges, inlays and onlays adjustments only)
Implants Not covered Not covered
Orthodontics Not covered Not covered
Monthly rates per person $34.28 $24.66 $23.25
Note: Information in grid represents in-network benefits.
The six-month waiting period for minor restorative services (adult Silver, Gold or Platinum plans) and the six-month waiting period for major
3
restorative services (adult Gold or Platinum plans) will be waived if you meet the following criteria:
¡ Your application is received within 30 days of the termination date of your previous coverage; and
¡ No later than 60 days from the effective date of your new policy with Arkansas Blue Cross and Blue Shield, you provide us with:
- A copy of your previous dental policy Certificate of Coverage, which reflects the policy’s effective and termination dates; and
- A copy of your previous policy’s benefit schedule, which reflects at least six months of coverage for minor and/or major restorative services.
In order to waive the minor and major restorative waiting periods, previous coverage must include comprehensive major restorative services such
as crowns and bridges.
4
GOLD PLATINUM
Child (Age 0-18) Adult (Age 19+) Child (Age 0-18) Adult (Age 19+)
Unlimited $1,000 Unlimited $1,500
$375 for one child; $375 for one child;
$750 for two or Unlimited $750 for two or Unlimited
more children more children
6 months 6 months
None None
(minor and major restorative) (minor and major restorative)
None Yes None Yes
Yes Yes
MEMBER PAYS (IN NETWORK)
$35 $20
0% coinsurance No coinsurance
0% coinsurance after deductible
after deductible or deductible
20% coinsurance after deductible 20% coinsurance after deductible
50% coinsurance after deductible 50% coinsurance after deductible
Not covered Covered Not covered Covered
Not covered Not covered
MONTHLY RATES (PER PERSON)
$32.21 $37.08 $34.28 $45.39
5Vision Coverage
Gold Plus Vision and Platinum Plus Vision Benefits
PLAN COVERAGE THROUGH A VSP NETWORK DOCTOR
Benefit Description (Frequency: Every 12 months)
Annual eye exam • Eye exam covered in full after $10 copay
• Glass or plastic, single vision, lined bifocal,
lined trifocal or lenticular prescription
lenses are covered in full after $25 copay
• Oversize lenses, scratch-resistant
coating covered in full
• Polycarbonate lenses are covered in
Lenses
full for children (ages 18 and under)
• Most popular lens enhancements are also
covered, subject to an additional copay4,5 In addition to all of the dental benefits, with
• 20% savings on additional glasses or Dental Gold Plus Vision and Dental Platinum
sunglasses, within 12 months of vision Plus Vision, you have:
exam5,6 • Coverage for eye examinations and
• Frames are covered in full7 up to $125 eyeglasses or contact lenses
allowance5 • The ability to maximize your benefits by
Frames
• 20% off any amount exceeding using an eye doctor or eye care center in
allowance5 the network10
• The freedom to choose any eye doctor10
• Elective contact lens materials (instead
of glasses) are covered in full up to $100 To shop our stand-alone Vision plans, visit
allowance arkbluecross.com/vision.
Contact lenses • 15% savings on contact lens exam
services; copay not to exceed $605 4
Most popular lens enhancements include progressives,
• Find additional savings on contact lenses anti-reflective, photochromics, polycarbonate, plastic dyes,
by clicking on “special offers” at vsp.com and UV protection. All other lens enhancements also available
at 20% savings.
VALUE-ADDED BENEFIT Based on applicable laws; benefits may vary by location.
5
6
Discounts valid through any VSP network doctor within 12 months
of the last covered eye exam.
• VSP-contracted laser centers provide 7
Less any applicable copay.
discounts for laser surgery, including 8
Custom LASIK coverage only available using wavefront technology
photo refractive keratectomy (PRK), with the microkeratome surgical device. Other LASIK procedures
Custom PRK, LASIK, Custom LASIK, and may be performed at an additional cost to the member.
Intralase.8
9
The VSP Laser VisionCare Program® is a discount plan only.
VSP Laser Discounts only apply to services received from a VSP participating
• VSP has negotiated special pricing with
VisionCareSM laser center. No monetary benefits are payable to members under
participating centers, which can add up this program.
Program
to hundreds of dollars in savings for VSP 10
It will cost more to visit an out-of-network eye doctor. To see
members. Contact the centers near you to which eye doctors are in the network, visit vsp.com.
11
Platinum Plus Vision includes the SunCare benefit.
learn more about their pricing.9
• Find a VSP-contracted Laser VisionCare SunCare benefit: If a vision examination does not result in a need
provider at vsp.com. for corrective vision materials, you may use your vision materials
benefits (frame and lens) to purchase non-prescription sunglasses
DENTAL GOLD PLUS VISION MONTHLY RATES (PER PERSON) from a participating provider’s frame board. Non-prescription
sunglasses purchased under this benefit exhaust your frame and
Child Adult lens benefits for the frequency period. This means if you use this
$38.61 $43.48 benefit to purchase non-prescription sunglasses, you are not eligible
(age 0-18) (age 19 and up)
for additional vision materials benefits until the completion of the
next frequency period.
DENTAL PLATINUM PLUS VISION MONTHLY RATES (PER PERSON)
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Child Adult ©2022 Vision Service Plan. All rights reserved. VSP and VSP
$40.87 $51.98 Safety Plan are registered trademarks, and Laser VisionCare is a
(age 0-18) (age 19 and up) service mark of Vision Service Plan.
6Most Popular Lens Enhancements
For Dental Gold Plus Vision and Platinum Plus Vision Plans
Most lens enhancements are covered after a copay, saving members an average of 20%-25%
LENS ENHANCEMENT Single Vision12 Multifocal12 SOLID TINTS AND DYES
Solid tints and dyes (Pink I and II) $0 $0 Solid color tints and dyes are not only
Solid tints and dyes fashionable, they also reduce the amount
$15 $15
(except Pink I and II) of light coming through the lenses.
Plastic gradient dye $17 $17
PLASTIC GRADIENT DYES
UV protection $16 $16 Gradient dyes are usually dark at the top
Polycarbonate lenses (for adults) and gradually lighten toward the bottom
Covered in full for dependent children $31 $35 of the lenses.
(ages 18 and under)
Anti-reflective coating $41 $41 UV PROTECTION
The combination of UV protection that’s
Photochromic lenses $70 $82
built into lenses and applied as a coating
Standard progressive N/A $55
can block 98%-100% of transmitted and
Premium progressive N/A $95 – $105 reflected UVA and UVB rays.
Custom progressive N/A $150 – $175
POLYCARBONATE LENSES
Prices shown reflect the standard plastic price for each respective category. Premium lens enhancement
12
prices may vary. Prices are valid only through VSP network doctors and are subject to change without notice. Polycarbonate lenses are made of
one of the thinnest, lightest and most
impact-resistant materials available. Plus,
they provide UV protection and scratch
resistance.
ANTI-REFLECTIVE COATING
Anti-reflective coating can reduce
eyestrain caused from glare, reflections
and the “halos” you see around lights at
night. Plus, it helps protect your lenses
from scratches and smudges and can
repel dust and water.
PHOTOCHROMIC LENSES
Photochromic lenses automatically
darken when exposed to sunlight and
lighten when out of sunlight.
PROGRESSIVE LENSES
Unlike traditional bifocal and trifocal
lenses that have lines, progressive lenses
are line-free.
7IMPORTANT INFORMATION and limited to one sealant per tooth per partial denture resin crowns, retainer or
To be eligible for an Arkansas Blue Cross lifetime; stainless steel crowns for those pontics on permanent teeth; orthodontic
dental insurance policy, you must be an under the age of 14, crown lengthening and treatment for any reason is not covered;
Arkansas resident. Other eligibility rules may guided tissue regeneration are limited to one hospital or anesthesia fees due to the
apply. Dependents who become ineligible per tooth per lifetime. Removable prosthetics management of the patient; hospital facility
may continue their coverage by completing a including complete and partial dentures are fees for dental services; biopsy of oral tissue;
new dental plan application within 30 days of limited to one per each five-year period. sutures of small wounds and complicated
becoming ineligible for coverage under their sutures; occlusal guard.
existing policy. At that time, the policyholder ADULT BENEFIT LIMITATIONS | for Silver, Gold,
will be credited for any waiting and Gold Plus Vision, Platinum and Platinum Plus GENERAL VISION | Coverage Limitations
frequency periods met and will begin a new Vision Plans All vision benefits are based on the frequency
dental benefit year; however, credit will not Routine dental exams, prophylaxis are periods, copayments and discounts stated
be given for a met deductible. This outline of limited to two in a calendar year; bitewing in the policy. Vision exams and materials are
coverage provides a brief description of the X-rays (one occurrence of two, three, four further limited to the allowable charge as
important features of the dental insurance or eight vertical bitewings for adults 19 and determined by the company. Any amount
policy. This outline is not the policy, and older) are limited to one in a calendar year; over the allowable charge is the covered
only the actual policy provisions will control. comprehensive dental evaluations are limited person’s responsibility.
Children age 26 and above are not eligible to to one per covered person every 24 months; The following items are excluded under
apply for coverage on a parent’s plan. These full mouth radiographs and single crowns are this plan:
policies are represented by the following limited to one per each five-year period; root
form numbers: Two pairs of glasses instead of bifocals
canal therapy is limited to one per tooth per
Replacement of lenses, frames or contacts
lifetime.
Dental Pediatric Plan 64-314 (Off Medical or surgical treatment
Marketplace), 64-315 (On Marketplace); Orthoptics, vision training or supplemental
ADULT BENEFIT LIMITATIONS | for Gold, Gold Plus testing
Dental Silver Plan 64-316 (Off Vision, Platinum and Platinum Plus Vision Plans
Items not covered under the contact lens
Marketplace), 64-317 (On Marketplace); Rebasing/relining of full or partial dentures
is limited to one in a three-year period; coverage:
Dental Gold Plan 64-318 (Off Marketplace),
inlays and onlays for treatment of decay, Insurance policies or service agreements
64-319 (On Marketplace); Dental Gold Plus single crowns, crown build ups including Artistically painted or nonprescription
Vision Plan 64-320 (Off Marketplace), 64-321 pins, removable prosthetics, partial denture lenses
(On Marketplace); Dental Platinum 64-364 retainers, post and cores are limited to one Additional office visits for contact lens
per each five-year period; crown lengthening pathology
(Off Marketplace), 64-365 (On Marketplace);
and guided tissue regeneration are limited to Contact lens modification, polishing or
Dental Platinum Plus Vision 64-366 (Off one per tooth per lifetime. cleaning
Marketplace), 64-367 (On Marketplace)
PEDIATRIC AND ADULT BENEFIT EXCLUSIONS | VISION | Out-of-Network Reimbursement
The policy itself sets forth in detail the
rights and obligations of both you and the
for all Plans If you choose an out-of-network vision
Orthodontic services; services, procedures provider, you pay the provider directly
insurance company. It is therefore important
or supplies not dentally necessary; services for all charges and then submit a claim
that you read the policy carefully. This
or procedures not prescribed or rendered for reimbursement. Out-of-network
policy is guaranteed renewable as long as
by a dentist; services or supplies collectible reimbursement includes:
you reside in Arkansas. The company may
under Worker’s Compensation; services for
change the established premium rate, but Eye exam — $45
conditions for which treatment is provided by
only if the rate is changed for all policies Single vision lenses — $30
federal or state government or are provided
and riders of the same form number and
without cost; accidental injuries, injuries or Bifocals — $50
premium classification.
diseases caused by war; cosmetic services; Progressives — $50
prescription drugs; local or block anesthesia Trifocals — $65
WAITING PERIODS when billed separately; experimental or
For individuals age 19 or older, some dental Lenticular — $100
investigational services; services provided by
plans contain waiting periods prior to certain an immediate relative. Frame — $70
services being covered. Once the waiting Elective contact lenses — $85
period is satisfied, those services are
payable, subject to all other terms, conditions,
COVERED PERSONS 19 AND OLDER BENEFIT Necessary contact lenses — $210
exclusions and limitations of the policy. EXCLUSIONS | for all Plans
Reevaluation limited, problem focused and
comprehensive periodontal evaluation; oral
PEDIATRIC BENEFIT LIMITATIONS | for Pediatric, surgery procedures for jaw deformities,
Silver, Gold, Gold Plus Vision, Platinum and Platinum resections, etc.; apically positioned
Plus Vision Plans flap procedure; enamel microbrasion;
Routine dental exams, prophylaxis, odontoplasty; sleep apnea appliances;
fluoride treatments and bitewing X-rays for biologic materials to aid in soft and osseous
dependent children under age 19 are limited tissues regeneration; provisional pontic and
to two in a calendar year; comprehensive titanium pontic; provisional retainer crown;
dental evaluations are limited to one per pediatric partial denture-fixed; mobilization 855-547-4589
covered person every 24 months; sealants
for permanent first and second molars only
of erupted or malpositioned tooth to aid
eruption; cytology sample collection; fixed
arkbluecross.com/dental
22D-ABCBS-0799
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