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Dental Blue® PPO

TO

Form No. 15-009 (03-08)

You think about finding affordable dental coverage.

n

We think our flexible and affordable dental benefits

will make you smile.

An Individual Stand-alone Dental Program

© 2008 Blue Cross of Idaho. An Independent Licensee of the Blue Cross and Blue Shield Association.

Blue Cross of Idaho District Offices

Boise (Street Address)

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

Coeur d’Alene 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 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

Maximum allowance for contracting or in-network dentists is based on a pre-negotiated payment amount. Maximum allowance for non-contracting or out-of-network dentists is based on a calculation of the average charges of Idaho dentists.

EnrollmentTo enroll in Dental Blue PPO, you must be an Idaho resident under age 65 and who does not have other Blue Cross of Idaho dental insurance coverage. If you choose to terminate enrollment in Dental Blue PPO, enrollment also terminates for your eligible dependents. Also, you and your dependents are not eligible to apply for Dental Blue PPO coverage for 24 months following the date of termination. One exception is if you terminate your policy and your dependent immediately enrolls in his or her own Dental Blue PPO policy with no break in coverage.

General Exclusions and LimitationsNo benefits are available for services that are:

n Not specifically included in the Closed List of Dental Covered Services;

n Considered to be not medically necessary or experimental in nature;

n Rendered prior to your effective date of coverage; orn Not prescribed by a dental care provider.For a complete list of exclusions and limitations, please see the policy.

This brochure describes the general features of the Dental Blue

PPO program; it is not a contract. Policy #3-390-1000-08/03

or Policy #3-390-1500-08/03 is the actual contract. All of the

provisions of the Policy apply. The benefits of the Policy are

governed primarily by the laws of the State of Idaho.

Paym

ent Options (1st m

onths premium

required with application – N

o $2 service fee required on first month)

❐ A

utomatic m

onthly bank withdraw

al (complete authorization below

) ❐

Monthly – direct coupon (paym

ent must include $2 m

onthly service fee)

Authorization A

greement for B

ank Withdraw

al

I or we, m

eaning my spouse if applicable, authorize and re-

quest Blue C

ross of Idaho (hereafter called BC

I) to affect paym

ent for premium

s I or we ow

e to BC

I as they become

due by initiating debit entries (hereafter called deductions) to m

y or our account in the institution named (hereafter called

the bank). I or we authorize and request the bank to accept any

deductions initiated by BC

I to my or our account. B

CI assum

es full responsibility for correctly inform

ing the bank of the specific am

ount of each deduction. I or we m

ay terminate this agreem

ent at any tim

e by notifying BC

I or the bank in writing. Term

ination will

take effect after BC

I or the bank has received the written notice

and had a reasonable amount of tim

e to act on it.

Bank N

ame _________________________________________________________________

Bank A

ddress (city, state) _______________________________________________________

Custom

er Bank A

ccount No.________________________

C

ompany I.D

. No. 0000500005

Signed ________________________________________________ D

ate _________________

Signed ________________________________________________ D

ate _________________

Transit R

outing No.

Account N

umber

Please attach voided check for autom

atic bank withdraw

al.

Statement of U

nderstanding

By signing this application, I represent that all m

y answers are com

plete and accurate, and that I understand and agree to the follow

ing conditions:• N

o Independent Producer, agent or employee of B

lue Cross of Idaho m

ay alter any part of this application or w

aive the requirement that I answ

er all questions completely

and accurately, nor may any such person change the term

s of the policy, except by endorsem

ent issued expressly for that purpose over the signature or facsimile signature

of the President of Blue C

ross of Idaho.• B

lue Cross of Idaho m

ay deny benefits or terminate or rescind m

y policy retroactive to its effective date for any m

isrepresentation, omission, or concealm

ent of fact by, concerning, or on behalf of any persons listed on this application that w

as or would have been m

aterial to B

lue Cross of Idaho’s acceptance of a risk, extension of coverage, provision of benefits,

or payment of any claim

.• If

this application

is not

approved, any

payment

submitted

with

this application

will be refunded. U

pon the refund of the payment, B

lue Cross of Idaho w

ill have no further obligations to m

e or any family m

ember listed on this application.

• If this application is approved, coverage for myself and any eligible fam

ily mem

bers nam

ed on this application will begin on the date assigned by B

lue Cross of Idaho.

• If this application is approved, I understand a copy of the application will be attached

to my policy. I approve the inclusion of any needed alterations to the application as long

as I have been consulted by a duly authorized employee of B

lue Cross of Idaho or a

licensed and duly appointed Independent Producer representing me, and I have had an

opportunity to review the application that w

ill be attached to my policy.

• This plan includes waiting periods. Preventive and diagnostic services do not have a

waiting period. B

asic services have a six month w

aiting period. Major services have a

12 month w

aiting period.• I acknow

ledge and understand my health plan m

ay request or disclose health inform

ation about me or m

y dependents (persons who are listed for benefits

coverage on the enrollment form

) from tim

e to time for the purpose of facilitating

health care

treatment,

payment

or for

the purpose

of business

operations necessary to adm

inister health care benefits; or as required by law. For m

ore inform

ation about such uses and disclosures, including uses and disclosures required by law

, please refer to the Blue C

ross of Idaho Notice of Privacy Practices

that is available at ww

w.b

cidah

o.co

m.

• I affirm that I have review

ed all answers given on this application and, if an

independent producer or other person has filled out the answers for m

e, I verify that the answ

ers are true and complete. I understand that this application is a

legal document and w

ill become part of the contract betw

een Blue C

ross of Idaho and the enrollee.

X _____________________________________________

________________

Applicant’s S

ignature

Date

(Parent or G

uardian's signature if applicant is under age 18)

X _____________________________________________

________________

Spouse’s S

ignature (if listed on application)

Date

For Independent P

roducers Only

Independent Producer C

hecklist

❒Is the application com

pleted in ink and signed by the applicant, and spouse, if applicable? (A dependent’s signature is not acceptable.)

❒A

re all questions regarding other coverage information com

pleted? ❒

Is all the legal paperwork to add special dependents, including the Judge’s signature in the case of adoptions, attached to the application?

❒Is the requested effective date on the first page filled in?

❒Is the A

uthorization Agreem

ent for Bank W

ithdrawal section filled out and signed, and a voided check attached, if m

onthly automatic

bank withdraw

al is requested in the Payment O

ption section?❒

Are all paym

ents attached to the front of the application?❒

If one check is written for split applications, is a breakdow

n of amounts that apply to each application included?

Independent Producer C

ertification

1. W

ho actually completed this application? ❒

Applicant ❒

Independent Producer ❒ O

ther

If Independent Producer or O

ther, please explain ______________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________________________

2. W

ere you present at the time the application w

as filled out? ❒ YES ❒

NO

If NO, please explain ________________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________________________

3. W

as money collected from

the applicant? ❒ YES ❒

NO Amount $ __________________________________________________________________________________

I have explained the eligibility provisions to the applicant. I have not made any representations about benefits, conditions, or lim

itations of the policy except through written m

aterial furnished by B

lue Cross of Idaho. I hereby certify that the inform

ation supplied to me by the applicant has been com

pletely and accurately recorded.

_________________________________________________

_______________________________________________

_____________________ ____________________________

Independent P

roducer’s Printed N

ame

Independent Producer’s S

ignature D

ate B

lue Cross of Idaho N

o.

Type of C

ompany A

ppointment ❐

Personal ❐

Agency (N

ame) _________________________________________________________________________________

....

Transit AB

A❐

Checking ❐

Savings

We know you are concerned about the cost of dental care for you and your family. We are excited to offer Dental Blue PPO, an individual dental plan that is flexible and affordable.

The PPO AdvantageYou have the flexibility of choosing your own provider. Dental Blue PPO is a Preferred Provider Organization (PPO) policy, which means that in order to save money, you should choose providers from our PPO contracting network. Blue Cross of Idaho has PPO agreements with dentists throughout Idaho so that you are not billed more than an amount Blue Cross of Idaho has determined to be the maximum allowance for a covered service.

When dental services are provided by a contracting (in-network) dentist, you will be responsible only for the deductible, coinsurance, copayment, and noncovered amounts.

When covered dental services are provided by a noncontracting (out-of-network) dentist, you will be responsible for any deductible, coinsurance, copayment, noncovered amounts, and amounts that exceed our maximum allowance.

DeductibleThere is a benefit period deductible of $50 per person, with a maximum of three benefit period deductibles per family. The deductible does not apply to in-network preventive covered services.

Benefit Period Maximum AmountDental Blue PPO provides coverage up to the $1,000 or $1,500 benefit period maximum, depending upon the option you feel is right for your family. The maximum benefit amount you choose is per insured per benefit period. Your benefit period is the twelve months following your effective date.

Preventive Dental BenefitsDental Blue PPO pays 100% of the maximum allowance for in-network services after a $20 copayment. Out-of-network services are paid at 70% of the maximum allowance after you meet your deductible. Available benefits include one oral exam every six months, x-rays, cleanings, and fluoride treatments. Certain benefits are only available to dependent children with age maximums. In-network preventive care services are not subject to deductible.

Basic Care BenefitsBasic care benefits cover frequently used services such as fillings and extractions. Basic care services are eligible for payment after the benefit period deductible and a six-month waiting period are met.

Dental Blue PPO pays 80% of the maximum allowance for in-network services and 60% of the maximum allowance for out-of-network services.

Major Care Benefits

Major care benefits of Dental Blue PPO include crowns, bridgework and root canal therapy. Major care services are eligible for payment after the benefit period deductible and a 12-month waiting period are met.

For major care services, Dental Blue PPO pays 50% of the maximum allowance for in-network services and 40% of the maximum allowance for out-of-network services.

Predetermination of BenefitsWhen a recommended Dental Treatment Plan includes crowns, full or partial dentures, inlays/onlays, periodontal surgery, bridgework, or surgical removal of impacted teeth, the Dental Treatment Plan must be submitted to Blue Cross of Idaho for a predetermination of benefits before treatment begins.

Maximum AllowanceMaximum 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.

(continued)

Please note that there is a six-month waiting period for basic care benefits and a 12-month waiting period for major care benefits.

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. Box

740

8, B

oise

, ID

837

07-1

408

• (2

08) 3

45-4

550

Form

No.

15-

008

(05-

06)

/

/

/

/

/

/

/

/

/

/

/

/

/

/

Dental Blue® PPO – An Individual Dental Program

Covered Services In-Network Out-of-Network

Deductible $50 per insured per benefit period

Benefit Period Maximum $1,000 or $1,500 per benefit period

Preventive Care Services $20 per visit copayment 70% of the maximum allowance3

Basic Care Services1 80% of the maximum allowance3 60% of the maximum allowance3

Major Care Services2 50% of the maximum allowance3 40% of the maximum allowance3

1 Basic care services have a six-month waiting period2 Major care services have a 12-month waiting period3 Deductible applies to out-of-network preventive services and in- or out-of-network basic and major services