One mission: you Dental Plans. for Groups. Policy Form Numbers: (11-09) (11-09) (09-12) (01-15) Form No.

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1 One mission: you 2017 Dental Plans for Groups Form No (10-16) Policy Form Numbers: (11-09) (11-09) (09-12) (01-15)

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3 BLUE CROSS OF IDAHO HEALTH INSURANCE PLANS / DENTAL FOR GROUPS Dental Plans Idaho employers have a difficult job: balancing the need to manage costs while providing employees with affordable, quality dental benefits. BLUE CROSS OF IDAHO WANTS TO MAKE YOUR JOB EASIER At Blue Cross of Idaho, we are dedicated to delivering the best value in dental insurance to our customers. We offer a variety of dental plan benefits to make sure s receive the dental services they need with affordable coverage options. ADDING VALUE THROUGH BETTER ACCESS AND PRICES Blue Cross of Idaho has extensive dental provider networks in Idaho and nationwide, giving our members choice and convenience for their dental care. DENTAL COVERAGE WHEREVER YOU ARE Blue Cross of Idaho has joined forces with other participating Blue Cross Blue Shield plans nationwide for exclusive access to the national Dental GRID, one of the country s largest networks of dental providers, which allows our members in-network benefits nationwide. When choosing Blue Cross of Idaho for your dental and medical coverage, you get the added value and convenience of one billing contact, one account manager and one renewal all designed to help you manage your healthcare programs. The contracting dentists in our traditional and preferred provider organization (PPO) networks agree to recognize our maximum allowance as their maximum fee for eligible services. ENSURING QUALITY BY MANAGING YOUR BENEFITS Quality is important to Blue Cross of Idaho. Our customer advocates and claims staff earn high marks from our providers and their staffs. Our on-site dental consultants ensure that the dental treatments provided to our members are appropriate and costeffective. bcidaho.com 1

4 VALUE-ADDED BENEFIT: DENTAL MAXIMUM CARRYOVER Dental Maximum Carryover adds value to your Blue Cross of Idaho dental benefits by encouraging s to take advantage of the low or no-cost routine preventive dental care cleanings and exams to improve overall oral health and by providing extra dollars for future dental services. IF YOU DON T USE IT, YOU DON T LOSE IT When s use $500 or less for dental claims in a benefit period, we carry over $250 to be used in the future. Carryover dollars may be used to pay for covered dental services once the benefit period maximum has been reached, saving s outof-pocket expenses.... CAVITIES AREN T JUST FOR KIDS! Changes that occur with aging make cavities an adult problem too. Regression of the gums can expose tooth roots to plaque which leads to decay. Decay around the edges of fillings is also common in adults. Over the years, fillings weaken and can fracture and leak. Bacteria accumulate in these cracks and can cause decay.... 2

5 BLUE CROSS OF IDAHO HEALTH INSURANCE PLANS / DENTAL FOR GROUPS ACA QUALIFIED PLANS FOR SMALL GROUPS (2-50 EMPLOYEES) Our Group Dental Choice sm and Group Dental Choice Plus sm plans offer low deductibles and low out-of-pocket maximums with no waiting periods for Basic and Major Dental Services for covered members age 18 and younger. Small Group Dental Plans (2-50 employees) DENTAL CHOICE (Age 18 and Younger) DENTAL CHOICE (Age 19 and Older) In-Network Out-of-Network In-Network Out-of-Network Individual Deductible $0 per member, per benefit period $100 per member, per benefit period $50 per member, per benefit period $100 per member, per benefit period Annual Out-of- Pocket Maximum $350 Individual/ $700 Two or more $10,000 None None Benefit Period Maximum None None $1,000 Preventive Dental Services (No waiting period; Includes exams, x-rays, cleaning and fluoride) pays $55 pays $25 Basic Dental Services (Includes fillings, extractions, and oral surgery) 6-month waiting period for members age 19 and older Major Dental Services (crowns, bridges & dentures, inlays/onlays, repairs to bridges & dentures, crown repair and dental Implants) 12-month waiting period for members age 19 and older Orthodontia pays 80% Orthodontia (For non-cosmetic orthodontia in accordance with Blue Cross of Idaho s medical policies; medically-necessary, non-cosmetic treatment; prior authorization required). No Benefit No Benefit This brochure describes the general features of our dental plans. It is not a contract. All the provisions of the Policy issued to the group apply. The benefits of the Policy are governed primarily by the laws of the State of Idaho. bcidaho.com 3

6 Healthy employees have a direct impact on your success and good oral health contributes to overall health. Small Group Dental Plans (2-50 employees) DENTAL CHOICE PLUS (Age 18 and younger) DENTAL CHOICE PLUS (Age 19 and Older) In-Network Out-of-Network In-Network Out-of-Network Individual Deductible $0 per member, per benefit period $100 per member, per benefit period $50 per member, per benefit period $100 per member, per benefit period Annual Out-of- Pocket Maximum $350 Individual/ $700 Two or more $10,000 None None Benefit Period Maximum None None $1,000 Preventive Dental Services (No waiting period; Includes exams, x-rays, cleaning and fluoride) pays $45 pays $10 Basic Dental Services (Includes fillings, extractions, and oral surgery) pays 20% pays 20% 6-month waiting period for members age 19 and older Major Dental Services (crowns, bridges & dentures, inlays/onlays, repairs to bridges & dentures, crown repair and dental Implants) 12-month waiting period for members age 19 and older Orthodontia pays 80% Orthodontia (For non-cosmetic orthodontia in accordance with Blue Cross of Idaho s medical policies; medically-necessary, non-cosmetic treatment; prior authorization required). No Benefit No Benefit This brochure describes the general features of our dental plans. It is not a contract. All the provisions of the Policy issued to the group apply. The benefits of the Policy are governed primarily by the laws of the State of Idaho. ORTHODONTIC VALUES If you are a Blue Cross of Idaho member and do not have orthodontia coverage, you will receive a $400 discount off the total cost of full orthodontic treatment plans for eligible family members. All you have to do is show the Blue Extras! Orthodontic Values Provider your Blue Cross member ID card. The discount applies to any treatment plan which is initiated after the orthodontist s effective date. Find the list of Orthodontic Values providers at members. bcidaho.com. Select Health & Wellness, then Discount Programs. Blue Extras! is a value-added program and not a part of your group insurance coverage. 4

7 BLUE CROSS OF IDAHO HEALTH INSURANCE PLANS / DENTAL FOR GROUPS Plans for all size groups Dental plans are available for groups with more than two employees, with a minimum 75 percent employee participation. Orthodontia is available for groups of 51 or more employees. Employer must contribute at least 50 percent of the monthly premium rate for each enrolled employee. There is no minimum contribution requirement for dependent coverage. PREFERRED BLUE DENTAL Preferred Blue Dental plans maximize consumer choice and flexibility while delivering reduced premiums and lower outof-pocket expenses. That s because Preferred Blue Dental provides higher benefits when seeking dental services from our network of PPO dental providers. Group Dental Plans PREFERRED BLUE DENTAL OPTION 1 PREFERRED BLUE DENTAL OPTION 2 PREFERRED BLUE DENTAL OPTION 3 In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network Deductible (per person, 3 family member maximum) Benefit Period Maximum (per person) Dental Provider Network $25 or $50 $25 or $50 $25 or $50 $1,000, $1,250 or $1,500 $1,000, $1,250 or $1,500 $1,000, $1,250 or $1,500 PPO PPO PPO Preventive Dental Services (Includes oral exams, x-rays and cleaning, and fluoride treatments) pays nothing. pays 20% pays 20%. pays 20% pays 20%. pays 50% Basic Dental Services (Includes fillings, extractions and oral surgery.) Deductible applies. Optional 6-month waiting period. pays 20% pays 30% pays 20% pays 30% pays 20% pays 50% Major Dental Services (crowns, bridges & dentures, inlays/onlays, repairs to bridges & dentures, crown repair and dental implants. ) Deductible applies. Optional 12-month waiting period. pays 50% pays 60% pays 50% pays 60% pays 50% pays 50% Orthodontia (for groups of 51+ employees) amount. (Lifetime Maximum of $1,000, $1,250 or $1,500) Please Note: These plans do not meet the ACA coverage requirement for those younger than age 19. This brochure describes the general features of our dental plans. It is not a contract. All the provisions of the Policy issued to the group apply. The benefits of the Policy are governed primarily by the laws of the State of Idaho. bcidaho.com 5

8 DEDUCTIBLE DENTAL Deductible Dental has the flexibility you need when providing dental benefits to s and their families. Preventive and diagnostic services are paid at 100 percent, basic dental services at 80 percent, and major dental services at 50 percent. A deductible applies to basic and major dental services. INCENTIVE DENTAL With Incentive Dental, s are rewarded for taking care of their smiles! Starting at 70 percent, benefit payments increase 10 percent each year up to 100 percent for preventive, diagnostic and basic dental services, as long as they visit a dental provider each consecutive year. For each year that a member does not receive dental services, the amount payable will decrease by 10 percent. Major dental services are covered at 50 percent with no Group Dental Plans DEDUCTIBLE AND INCENTIVE DENTAL Deductible Dental Incentive Dental 1 Tips for preventing cavities Eat nutritious and balanced meals and limit snacking. Check with your dentist about the use of supplemental fluoride and dental sealants (protective coating for back teeth). Visit your dentist regularly for exams and cleanings. Deductible (per person, 3 family member maximum) Benefit Period Maximum (per person) Dental Provider Network Preventive Dental Services (Includes oral exams, x-rays and cleaning, and fluoride treatments) Basic Dental Services (Includes fillings, extractions and oral surgery.) Deductible applies. Optional 6-month waiting period. Major Dental Services (crowns, bridges & dentures, inlays/onlays, repairs to bridges & dentures, crown repair and dental implants.) Deductible applies. Optional 12-month waiting period. Orthodontia (for groups of 51+ employees) $25 or $50 No Deductible pays nothing. pays 20% $1,000, $1,250 or $1,500 Traditional or PPO pays 30% amount for 1st year; 20% for 2nd year; 10% for 3rd year; nothing in 4th year. pays 30% amount for 1st year; 20% for 2nd year; 10% for 3rd year; nothing in 4th year. No deductible applies. amount. No deductible applies. amount. (Lifetime Maximum of $1,000, $1,250 or $1,500) Footnotes: 1 Incentive Dental: must have at least one covered dental service per benefit period for incentive level to increase. Please Note: These plans do not meet the ACA coverage requirement for those under age 19. This brochure describes the general features of our dental plans. It is not a contract. All the provisions of the Policy issued to the group apply. The benefits of the Policy are governed primarily by the laws of the State of Idaho. 6

9 BLUE CROSS OF IDAHO HEALTH INSURANCE PLANS / DENTAL FOR GROUPS ESSENTIAL DENTAL Essential Dental is our low cost dental care option, providing your employees with benefits for preventive, diagnostic and basic dental services. Major dental services are not covered, which keeps premiums lower than other dental plans. VOLUNTARY DENTAL Voluntary Dental is a great way to provide s with easy access to dental care coverage. As implied by the name, the plan is entirely voluntary, meaning that s decide whether or not they want to participate. Voluntary Dental is available to groups with more than three employees. At least one employee must elect coverage. Employer contribution is optional. Note: Applicable waiting periods will be waived for initial enrollees transferring from another group plan to a Voluntary Dental plan. Group Dental Plans ESSENTIAL DENTAL In-Network Out-of- Network VOLUNTARY DENTAL PLAN A In-Network Out-of- Network Deductible (per person, 3 family member maximum) Benefit Period Maximum (per person) Dental Provider Network Preventive Dental Services (Includes oral exams, x-rays and cleaning, and fluoride treatments) Basic Dental Services (Includes fillings, extractions and oral surgery.) Major Dental Services (crowns, bridges & dentures, inlays/onlays, repairs to bridges & dentures, crown repair and dental implants) Orthodontia (for groups of 51+ employees) pays nothing. $25 or $50 $25 or $50 $50 or $75 $1,000 $1,000, $1,250 or $1,500 PPO pays 20% Benefits do not apply to Benefit Period Maximum. pays 20% pays 40% 6-month waiting period. Major Dental Services are not covered. Orthodontia services are not covered. pays nothing after $20 copayment per visit. pays 20% PPO pays 30% pays 50% 6-month waiting period. pays 50% pays 60% 12-month waiting period. amount. (Lifetime Maximum of $1,000, $1,250 or $1,500) 24-month waiting period. Please Note: These plans do not meet the ACA coverage requirement for those younger than age 19. This brochure describes the general features of our dental plans. It is not a contract. All the provisions of the Policy issued to the group apply. The benefits of the Policy are governed primarily by the laws of the State of Idaho. bcidaho.com 7

10 DENTAL BLUE CONNECT Blue Cross of Idaho is proud to partner with Willamette Dental Group, the Northwest s largest multi-specialty group dental practice, as our exclusive provider network for Dental Blue Connect. Our partnership and plan offers extensive in-network dental coverage with: No deductibles No annual maximum No waiting periods Dental Blue Connect offers you and s predictable, low out-of-pocket costs for covered dental services, low copayments and low monthly premium. Plus, orthodontic coverage is included for children and adults. Each Willamette Dental Group dentist works with patients to promote long-term dental health, rather than what s bothering the patient today. With more than 50 locations throughout the Pacific Northwest, there s likely a Willamette Dental Group office in your neighborhood. No claim forms Groups 2-99 Plan B Plan C Plan D Groups 100+ All Groups In-Network In-Network In-Network In-Network Out-of-Network Annual Maximum No annual maximum N/A Deductible No deductible N/A Waiting Period No waiting period N/A Office Visit Copayment Diagnostic & Preventive Services (i.e. routine/ emergency exams, x-ray, cleanings, fluoride, periodontal charting) Restorative dentistry (Crowns and fillings) pays $15 copayment pays $20 copayment pays $30 copayment Customized Copayment varies Copayment varies Copayment varies Copayment varies Prosthodontics (Dentures and bridges) Copayment varies Copayment varies Copayment varies Customized Endodontics and Periodontics Copayment varies Copayment varies Copayment varies Customized Oral Surgery (Routine extraction) Comprehensive Orthodontia Treatment Local Anesthesia, dental lab fees Nitrous Oxide pays $2,000 copayment pays $40 copayment pays $2,200 copayment pays $40 copayment pays $3,000 copayment pays $40 copayment Customized Customized Customized Please Note: These plans do not meet the ACA coverage requirement for those 18 and younger. Out-of-Network: If visits an out-of-network dentist, we reimburse him/her This brochure describes the general features of our dental plans. It is not a contract. All the provisions of the Policy issued to the group apply. The benefits of the Policy are governed primarily by the laws of the State of Idaho. 8

11 BLUE CROSS OF IDAHO HEALTH INSURANCE PLANS / DENTAL FOR GROUPS Exclusions & Limitations In addition to any other exclusions and limitations of the Policies, the following exclusions and limitations apply to dental services: There are no benefits for services, supplies, or other charges that are procedures that are not included in the Closed List of Dental Covered Services; or that are not Medically Necessary for the care of an Insured s covered dental condition; or that do not have uniform professional endorsement. Charges incurred for services that were started prior to the Insured s Effective Date. A service furnished to an Insured for cosmetic purposes, unless necessitated as a result of Accidental Injuries received while the Insured was covered by Blue Cross of Idaho. In excess of the Maximum Allowance. Any procedure, service or supply required directly or indirectly to treat a muscular, neural, orthopedic or skeletal disorder, dysfunction or Disease of the temporomandibular joint (jaw hinge) and its associated structures including, but not limited to, myofascial pain dysfunction syndrome. Temporary dental services. Charges for temporary services are considered an integral part of the final dental services and are not separately payable. Any service, procedure or supply for which the prognosis for success is not reasonably favorable. For hospital Inpatient or Outpatient care for extraction of teeth or other dental procedures. Not prescribed by or upon the direction of a Provider. Investigational in nature. Provided for any condition, Disease, Illness or Accidental Injury to the extent that the Insured is entitled to benefits under occupational coverage, obtained or provided by or through an employer under state or federal Workers Compensation Acts or under Employer Liability Acts or other laws providing compensation for work-related injuries or conditions. This exclusion applies whether or not the Insured claims such benefits or compensation or recovers losses from a third party. Provided or paid for by any federal governmental entity or unit except when payment under this Policy is expressly required by federal law, or provided or paid for by any state or local governmental entity or unit where its charges therefor would vary, or are or would be affected by the existence of coverage under this Policy; or for which payment has been made under Medicare Part A and/or Part B. Provided for any condition, Accidental Injury, Disease or Illness suffered as a result of any act of war or any war, declared or undeclared. Furnished by a Provider who is related to the Insured by blood or marriage and who ordinarily dwells in the Insured s household. Received from a dental, vision or medical department maintained by or on behalf of an employer, a mutual benefit association, labor union, trust or similar person or group. For personal hygiene, comfort, beautification or convenience items even if prescribed by a Dentist, including but not limited to, air conditioners, air purifiers, humidifiers, physical fitness equipment or programs. For telephone consultations; for failure to keep a scheduled visit or appointment; for completion of a claim form; or for personal mileage, transportation, food or lodging expenses, or for mileage, transportation, food or lodging expenses billed by a Dentist or other Provider. For Congenital Anomalies, or for developmental malformations, unless the patient is an Eligible Dependent child. For the treatment of injuries sustained while committing a felony, voluntarily taking part in a riot, or while engaging in an illegal act or occupation, unless such injuries are a result of a medical condition or domestic violence. Any services or supplies for which an Insured would have no legal obligation to pay in the absence of coverage under this Policy or any similar coverage; or for which no charge or a different charge is usually made in the absence of insurance coverage. Provided to persons who were enrolled as Eligible Dependents after they cease to qualify as Eligible Dependents due to a change in Eligibility status which occurs during the Policy term. Provided outside the United Sates, which if had been provided in the United States, would not be Covered Services under this Policy. Not directly related to the care and treatment of an actual condition, Illness, Disease or Accidental Injury. bcidaho.com 9

12 NONDISCRIMINATION STATEMENT Blue Cross of Idaho complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability or sex. Blue Cross of Idaho does not exclude people or treat them differently because of race, color, national origin, age, disability or sex. Blue Cross of Idaho: Provides free aids and services to people with disabilities to communicate effectively with us, such as: Qualified sign language interpreters Written information in other formats (large print, audio, accessible electronic formats, other formats) Provides free language services to people whose primary language is not English, such as: Qualified interpreters Information written in other languages If you need these services, contact Blue Cross of Idaho s Customer Service Department. Call (TTY: ), or call the customer service phone number on the back of your card. If you believe that Blue Cross of Idaho has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability or sex, you can file a grievance with Blue Cross of Idaho s Grievances and Appeals Department at: Manager, Grievances and Appeals 3000 East Pine Avenue, Meridian, Idaho Telephone: (800) ext.3838, Fax: TTY: You can file a grievance in person or by mail, fax, or . If you need help filing a grievance, our Grievances and Appeals team is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, , (TTY). Complaint forms are available at Reference: 10

13 BLUE CROSS OF IDAHO HEALTH INSURANCE PLANS / DENTAL FOR GROUPS LANGUAGE ASSISTANCE ATTENTION: If you speak Arabic, Chinese, French, German, Korean, Japanese, Persian (Farsi), Romanian, Russian, Serbo-Croatian, Spanish, Sudanic Fulfulde, Tagalog, Ukrainian, or Vietnamese, language assistance services, free of charge, are available to you. Call (TTY: ). Arabic ملظوحة: إ اذ كنت تتحدث اذكر اللغة فا ن خدمات المساعدة اللغویة تتوافر لك بالمجان. اتصل برقم (رقم اھتف الصم ولابكم: ). Chinese 注意 : 如果您使用繁體中文, 您可以免費獲得語言援助服務 請致電 (TTY: ) French ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le (ATS : ). German ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: (TTY: ). Japanese 注意事項 : 日本語を話される場合 無料の言語支援をご利用いただけます (TTY: ) まで お電話にてご連絡ください Korean 주의 : 한국어를사용하시는경우, 언어지원서비스를무료로이용하실수있습니다 (TTY: ) 번으로전화해주십시오. Persian-Farsi توجھ: گار بھ ا بزن فارسی گفتگو می دینک تسھیلات ینابز وص برت اگ ی ارن بریا شما فرا مھ می دش ا ب. با ( (TTY: تماس بگیردی. Romanian ATENȚIE: Dacă vorbiți limba română, vă stau la dispoziție servicii de asistență lingvistică, gratuit. Sunați la (TTY: ). Russian ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните (телетайп: ). Serbo-Croation OBAVJEŠTENJE: Ako govorite srpsko-hrvatski, usluge jezičke pomoći dostupne su vam besplatno. Nazovite (TTY- Telefon za osobe sa oštećenim govorom ili sluhom: ). Spanish ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (TTY: ). Sudanic Fulfulde MAANDO: To a waawi [Adamawa], e woodi ballooji-ma to ekkitaaki wolde caahu. Noddu (TTY: ). Tagalog PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa (TTY: ). Ukrainian УВАГА! Якщо ви розмовляєте українською мовою, ви можете звернутися до безкоштовної служби мовної підтримки. Телефонуйте за номером (телетайп: ). Vietnamese CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số (TTY: ). bcidaho.com 11

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16 One mission: you Meridian 3000 E. Pine Ave. Meridian, ID Lewiston Pocatello 275 S. 5 th Ave. Pocatello, ID Twin Falls 1503 Blue Lakes Blvd. N. Twin Falls, ID Idaho Falls 1910 Channing Way Idaho Falls, ID Coeur d Alene 1450 NW Blvd., Suite 106 Coeur d Alene, ID Blue Cross of Idaho Sales Customer Service bcidaho.com 2016 by Blue Cross of Idaho, an independent licensee of the Blue Cross and Blue Shield Association

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