Blue Cross of Idaho
District Offices
Boise
3000 East Pine Avenue
Meridian, ID 83642-5995
(Mailing Address)
P.O. Box 7408, Boise, ID 83707
(208) 387-6683
(800) 365-2345
(Dental Customer Service)
(208) 363-8755
(800) 289-7929
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Voluntary Dental Program
Coeur d’Alene
Even when providing dental benefits for your
employees doesn’t fit into the budget,
you can still provide a service that gives them
easy access to dental care coverage.
Idaho employers have a difficult job; balancing the
need to provide health care benefits to employees
while managing costs.
We want to make your job easier. Even if you cannot
afford to offer a dental plan, you can make it easier
for your employees to take care of their oral health by
offering our Voluntary Dental program. This program
does not require any employer contribution.
It’s easy to enroll. Just sign up for the Voluntary Dental
program as a group, listing the employees and their
dependents that choose to participate. There are
no minimum participation or employer contribution
requirements. You will be billed monthly for the entire
premium. Your payroll department will then deduct the
employees’ individual dental coverage premium.
Note: Voluntary Dental premiums qualify to be
deducted on a pre-tax basis.
2100 Northwest Boulevard, Suite 120
Coeur d’Alene, ID 83814
(208) 666-1495
Idaho Falls
2116 East 25th Street
Idaho Falls, ID 83404
(Mailing Address)
P.O. Box 2287, Idaho Falls, ID 83403
(208) 522-8813
Lewiston
1010 17th Street
(Mailing Address)
P.O. Box 1468, Lewiston, ID 83501
(208) 746-0531
Pocatello
275 South 5th Avenue, Suite 150
Pocatello, ID 83201
(Mailing Address)
P.O. Box 2578, Pocatello, ID 83206
(208) 232-6206
Twin Falls
This brochure describes the general features of the Voluntary Dental program; it is not a contract. Policy #3-140
(01/07) is the actual contract. All the provisions of the Policy apply. The benefits of the Policy are governed primarily
by the laws of the State of Idaho.
Let Blue Cross of Idaho be your dental coverage partner.
Contact your local Independent Insurance Agent or a Blue Cross of Idaho sales office near you.
1431 North Fillmore Street, Suite 200
Twin Falls, ID 83301
(Mailing Address)
P.O. Box 5025, Twin Falls, ID 83303-5025
(208) 733-7258
www.bcidaho.com
You think about finding a way
to provide dental benefits for
your employees.
n
We think our voluntary
dental program will make
everyone smile.
© 2008 Blue Cross of Idaho. An Independent Licensee
of the Blue Cross and Blue Shield Association.
Form No. 15-017 (04-08)
For Form No. 3-140 (01/07)
Give Your Employees Another Reason to Smile
The PPO Advantage
Voluntary Dental is a Preferred Provider Organization
(PPO) product, which means that in order to receive the
most in benefit payments, members should choose their
dentist from our PPO contracting network. We have PPO
agreements with dentists in Idaho and nationwide so our
members are not billed more than an amount Blue Cross
of Idaho has determined to be the maximum allowance for
an eligible service.
When dental services are provided by a contracting
(in-network) dentist, the member is only responsible for
any deductible, coinsurance, copayment and noncovered
amounts.
Deductible
With Voluntary Dental, you can choose a $25
in-network and $50 out-of-network per person deductible
or a $50 in-network and $75 out-of-network per person
deductible. Both options have a maximum of three benefit
period deductibles per family. The deductible does not
apply to in-network preventive covered services.
Basic Dental Services
The employee pays 20% – 70% of the maximum
allowance for in-network services and 50% – 70% of the
maximum allowance for out-of-network services. Basic
care services are eligible for payment after the benefit
period deductible and a six-month waiting period is met.
Available benefits include sealants, fillings and
extractions.
Major Dental Services
Voluntary Dental pays up to 50% of the maximum
allowance for in-network services. The employee pays
60% – 80% of the maximum allowance for out-of-network
services, depending on the plan chosen. Major care
services are eligible for payment after the benefit period
deductible and a 12-month waiting period are met.
Preventive Dental Services
Predetermination of Benefits
Voluntary Dental pays 100% of the maximum allowance
for in-network services with a $20, $25 or $30 copayment
depending upon the option chosen. The deductible
does not apply to in-network preventive services. The
employee pays 30% – 60% of the maximum allowance for
out-of-network services after the deductible has been met.
Available benefits include one oral exam every six
months, bitewing x-rays, cleanings and fluoride
treatments. Certain benefits are only available to
dependent children with age maximums.
Voluntary Dental is available to employees. If an
employee wishes to enroll their dependent(s), the
employee must enroll. If the employee chooses to
terminate enrollment in Voluntary Dental, enrollment is
terminated for their dependents as well.
When a recommended Dental Treatment Plan includes
crowns, bridges or dentures, the Dental Treatment
Plan must be submitted to Blue Cross of Idaho for a
predetermination of benefits before treatment begins.
Please note that there are waiting periods for basic and
major dental services.
Maximum Allowance
Maximum allowance is the lesser of the billed charge
or the amount established by Blue Cross of Idaho as the
highest level of payment for a service you receive that is
covered under this program.
No benefits are available for services that are:
nNot specifically included in the Closed List of Dental
Covered Services;
experimental in nature;
nRendered prior to the effective date of coverage; or
nNot prescribed by a dental care provider.
Benefit Period
Maximum
$1,000, $1,250, or $1,500
Deductible1
$25 In-Network / $50 Out-of-Network
$50 In-Network / $75 Out-of-Network
EMPLOYEE PAYS:
Plan A
Orthodontia Benefits (Optional)
Voluntary Dental provides coverage for up to $1,000,
$1,250 or $1,500 annually depending upon the option you
choose. The maximum benefit amount is per member, per
benefit period, which is the twelve months following your
group’s effective date.
General Exclusions and Limitations
nConsidered to be not medically necessary or
Enrollment
Available benefits include crowns, bridges and dentures,
root canal therapy and periodontal maintenance.
As an option to your group plan, you may add orthodontia
benefits. These benefits are available to enrolled
dependent children. Employees pay 50% of the maximum
allowance for covered services with a maximum lifetime
benefit of up to $1,000, $1,250 or $1,500 depending on
the option chosen, after a 24-month waiting period has
been met. The maximum paid per benefit period is $500.
Benefit Period Maximum Amount
Maximum allowance for contracting or in-network
dentists is based on a pre-negotiated payment amount.
Maximum allowance for non-contracting or out-ofnetwork dentists is based on a calculation of the average
charges of Idaho dentists.
Plan B
Out-of-Network
In-Network
Out-of-Network
In-Network
Out-of-Network
Preventive
Dental Services
Nothing after $20
copayment per visit
30%
(deductible applies)
Nothing after $25
copayment per visit
50%
(deductible applies)
Nothing after $30
copayment per visit
60%
(deductible applies)
Basic
Dental Services
Deductible applies
20%
6-month
waiting period
50%
6-month
waiting period
30%
6-month
waiting period
50%
6-month
waiting period
Year I = 60%
Year II = 50%
Year III = 40%
6-month
waiting period
70%
6-month
waiting period
Major
Dental Services
Deductible applies
50%
12-month
waiting period
60%
12-month
waiting period
60%
12-month
waiting period
70%
12-month
waiting period
Year I = 80%
Year II = 70%
Year III = 60%
12-month
waiting period
80%
12-month
waiting period
Orthodontia2
(Enrolled
dependent children)
50%
$1,000, $1,250, or $1,500 Lifetime Maximum ($500 maximum paid per benefit period)
24-month waiting period
The benefit period family deductible is satisfied after three insureds of the same
family have met their individual deductible. (No insured may contribute more than
the individual deductible amount toward the family deductible.)
1
2
Plan C
In-Network
Orthodontia benefits do not apply to the benefit period maximum.
Please Note: Payments are based on Blue Cross of Idaho maximum allowances.
Benefit Exclusions and Limitations
Preventive Dental Services
Oral exams limited to once in a six month period.
Bitewing X-rays limited to one time per benefit period.
Cleanings limited to once in a six month period.
Fluoride Treatment limited to one time per benefit period.
Basic Dental Services
Sealants limited to one time in a three year period for permanent unrestored
posterior teeth and limited to eligible dependent children under age 16.
Fillings for same tooth surface limited to once in a two year period.
Major Dental Services
Crowns, bridges and dentures limited to five year replacement.
Periodontal maintenance limited to once in a six month period.