Dependent children who turn age 26 – and divorced dependents –may continue their
coverage by completing a new DentalBlue application within 30 days of becoming ineligible
for coverage under their existing policy. At that time, the policyholder will be
credited for any met waiting and frequency periods and will begin a new benefit
year; however, credit will not be given for a met deductible.
This outline of coverage provides a brief description of the important features
of the DentalBlue insurance policy. This outline is not the policy, and only the
actual policy provisions will control. These policies are represented by the following
form numbers: 64-311 (DentalBlue Bronze), 64-312 (DentalBlue Silver), 64-313 (DentalBlue
Gold) and 17-278 (Vision).
The policy itself sets forth in detail the rights and obligations of both you and
the insurance company. It is, therefore, important that you read the policy carefully.
This policy is guaranteed renewable so long as you reside in Arkansas. The company
may change the established premium rate, but only if the rate is changed for all
policies and riders of the same form number and premium classification.
Some DentalBlue plans contain waiting periods prior to certain services being covered.
Once the waiting period is satisfied, those services are payable, subject to all
other terms, conditions, exclusions and limitations of the policy.
Dental and Vision Benefits and Services Not Included:
Orthodontic services; services, procedures or supplies not dentally necessary; services
or procedures not prescribed or rendered by a dentist or eye doctor; services or
supplies collectible under Workers’ Compensation or any law providing benefits for
dependents of military personnel; services for conditions for which treatment is
provided by federal or state government or are provided without cost; intentional
self-inflicted injuries; accidental injuries; injuries or diseases caused by war;
cosmetic services; prescription drugs; local or block anesthesia when billed separately;
experimental or investigational services; services provided by an immediate relative;
vision fees charged by a provider for services other than covered vision exam or
covered vision materials; orthophic or vision training, subnormal vision aids and
any associated supplemental testing and aniseikonic lenses; medical and/or surgical
treatment of the eye, eyes or supporting structures; any vision exam or connective
eyewear required by an employer as a condition of employment and/or safety eyewear
unless specifically covered under this policy; non-prescription lenses or non-prescription
sunglasses, medically necessary contact lenses for which Prior Approval was not
General Dental Coverage Limitations:
Routine dental exams, prophylaxis, (fluoride treatments, bitewing X–rays for dependent
children through age 18) are limited to two per benefit year; bitewing X–rays, one
occurrence of two, four or eight vertical bitewings for adults over age 18, are
limited to one per benefit year; comprehensive dental evaluations are limited to
one per covered person every 24 months; fixed space maintainers through age 18,
rebasing/relining of full or partial dentures, and sealants for dependents through
age 15 on permanent first and second molars are limited to one per each three-year
period; full mouth radiographs, inlays and onlays for treatment of decay, single
crowns, crown buildups including pins, removable prosthetics, resin-bonded retainers,
and post and core buildups are limited to one per each five-year period; stainless
steel, prefabricated resin or composite resin crowns; root canal therapy, crown
lengthening, and guided tissue regeneration are limited to one per tooth per lifetime.
General Vision Coverage Limitations:
All vision benefits are based on the frequency periods, copayments and discounts
stated in the policy. Vision exams and materials are further limited to the allowable
charge as determined by the company. Any amount over the allowable charge is the
covered person's responsibility.
Certificates of Coverage: