You must be a California resident to enroll in this plan. There is a six-month waiting period for minor services and no coverage for major services. $25 calendar-year deductible per member with $500 calendar year benefit maximum per member. This is a brief overview of the exclusions and limitations of the policy. Please review the Evidence of Coverage and Health Service Agreement before purchasing this plan.

Introduction to the Value Smile PPO:  Blue Shield’s dental plans are administered by a Dental Plan Administrator (DPA) which is a dental care service plan and which contracts with Blue Shield to underwrite and administer the delivery of dental services through a network of Participating Dentists.

Before Obtaining Dental Care Services: You are responsible for assuring that the Dentist you choose is a Participating Dentist. Note: A Participating Dentist’s status may change. It is your obligation to verify whether the Dentist you choose is currently a Participating Dentist in case there have been any changes to the list of Participating Dentists. A list of Participating Dentists located in your area, can be obtained by contacting a Dental Plan Administrator at 1- 888-679-8928. You may also access a list of Participating Dentists through Blue Shield Life’s internet site located at http://www.blueshieldca.com.

Choice of Dentists: The Value Smile PPO is specifically designed for you to use Participating Dentists. Participating Dentists agree to accept a Dental Plan Administrator’s payment, plus your payment of any applicable Deductible and Copayment, as payment in full for Covered Services. This is not true of Non-Participating Dentists. Participating Dentists submit claims for payment after Dental Care Services have been rendered. Payments for these claims go directly to the Participating Dentist. You or your Non- Participating Dentists submit claims for reimbursement after services have been rendered. If you receive Dental Care Services from Non-Participating Dentists, you have the option of having payments sent directly to the Non-Participating Dentist or sent directly to you. A Dental Plan Administrator will notify you of its determination within 30 days after receipt of the claim. Participating Dentists do not receive financial incentives or bonuses from Blue Shield Life.

Dental Necessity Exclusion All Services must be of Dental Necessity. The fact that a Dentist or other provider may prescribe, order, recommend, or approve a service does not, in itself, make it of Dental Necessity, even though it is not specifically listed as an exclusion or limitation. The Plan may limit or exclude benefits for services that are not of Dental Necessity.

Calendar Year Deductible: There is a Calendar Year Deductible of $25 that applies to all Covered Services and supplies furnished by Participating and Non-Participating Dentists 1. It is the amount that you must pay out of pocket before benefits will be provided for Covered Services. This Deductible applies each Calendar Year. This Deductible applies separately to each covered Insured, each Calendar Year. Except as noted, the Calendar Year Deductible of $25 applies to all covered Services and supplies furnished by Participating and Non-Participating Dentists. It is the amount that you must pay out of pocket before benefits will be provided for Covered Services. This Deductible applies each Calendar Year. The Calendar Year Deductible does not apply to those dental Services considered by Blue Shield Life to be diagnostic or preventive. Services that are considered diagnostic or preventive by Blue Shield Life are listed in the section entitled Summary of Benefits and Insured’s Copayments.

Calendar Year Maximum Payment: Your Plan pays up to a maximum of $500 each Calendar Year for Covered Services and supplies provided by any combination of Participating and Non-Participating Dentists.