4-Appendix D Current Dental PPO Plan Design 7-7-25.pdf

BlueCare DentalSM

Blue Cross and Blue Shield of New Mexico, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association

City of Albuquerque Effective: 7/1/2024

The following is a listing of common services available through your BlueCare Dental PPO network. The member’s share of the cost is determined by whether care is received from a contracted or non‑contracted provider. Your plan allows you to see any licensed dentist, but using an in-network provider may minimize your out-of-pocket expenses.

This information only provides highlights of this program. Please refer to the BlueCare Dental Certificate for additional detailed benefit information.

Summary of Dental Benefits PROGRAM BASICS In-Network Dentist Out-of-Network Dentist

MAC

Benefit Period Maximum: Calendar Year $1,500 $1,500

Deductible: Calendar Year $50 Individual $150 Family

$50 Individual $150 Family

Three Month Deductible Carryover Applies ☒ Yes ☐ No ☒ Yes ☐ No Prior Carrier Deductible Credit Applies ☐ Yes ☒ No ☐ Yes ☒ No

COVERED SERVICES

Class 1: Preventive Services (Deductible does not apply) Periodic Oral Evaluations Problem Focused Oral Evaluations Comprehensive Oral Evaluations Prophylaxis/routine cleanings X-rays Full‑Mouth, Pano, Bitewing, Periapical Sealants Topical Fluoride Space maintainers Perio Maintenance Palliative Treatment (emergency care to relieve pain)

100% 80%

Class 2: Basic Restorative Services Amalgam & Composite Fillings Non-surgical Extractions Full Mouth Debridement Scaling & Root Planning Denture Reline/Rebase Repairs – Crown & Bridge Oral Surgery & Surgical Extractions Endodontics (root canal) Major Periodontics

85% 85%

Class 3:

Major Restorative Services Bridges & Dentures Implants: Yes ☒ No ☐ Crowns, Inlays, Onlays Deep Sedation/General Anesthesia

50% 50%

Class 4:

Orthodontics Orthodontic Diagnostic Procedures & Treatment Coverage for Adults & Dependent Children (to age 26)

50%

50%

Lifetime Maximum Ortho Benefit per Participant $1,200 $1,200

PPO Plan

BlueCare DentalSM

Blue Cross and Blue Shield of New Mexico, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association

Benefit Limitations & Frequencies:

Oral Evaluations 2 per year

Comprehensive Evaluations 2 per 12 months

X-rays: Bitewings 2 per year

X-rays Full mouth panoramic 1 per 60 months

Prophy/Cleanings 2 per year

Fluoride Application 2 per year for children up to age 19

Sealants (per tooth) 1 per lifetime up to age 16

Space Maintainers 1 per lifetime up to age 14

Amalgam & Composite Fillings 1 per tooth per 12 months

Crowns/Dentures/Bridges/Implants Replacement every 5 years

Denture Reline/Rebase 1 per 36 months

Perio Maintenance 2 per year

Additional Features:

Missing Tooth Exclusion ☒ No Exclusion ☐ Yes Applies Benefit Waiting Period ☒ No Waiting Period ☐ Yes Applies Enhanced Dental Benefit ☐ Not Included ☒ Yes, included Graduated Annual Maximum ☒ Not Included ☐ Yes, included

Predetermination of benefits is recommended, but not required, for services in excess of $300.

This summary is intended to highlight the most common services and frequencies under the dental plan.

For complete and detailed descriptions of services, limitations, and exclusions, please refer to the certificate of coverage.

PPO Plan