Personal Dental Coverage with Optional VisionBlueSM. Affordable Dental Plans for Individuals of All Ages

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1 Personal Dental Coverage with Optional VisionBlueSM Affordable Dental Plans for Individuals of All Ages

2 When it comes to maintaining a healthy body, a good place to start is a healthy mouth. BlueCross BlueShield of Tennessee can help you take care of your smile with Personal Dental Coverage. Enjoy the Advantages of Personal Dental Coverage Freedom to Choose Any Provider Visit any dentist you want. You can access our DentalBlue network, which includes more than 3,000 dentists in one of Tennessee s largest PPO Dental networks. Convenient Automatic Claims Filing When you use network dentists, your claims will be filed automatically. This means no paperwork for you. Hassle-free Automatic Billing Pay your premiums electronically with automatic bank draft or credit card authorization. Check Benefit Information and Claims Status Online Use BlueAccess SM at bcbst.com to find your deductible, review annual limits and claims status, view copies of your Explanation of Benefits and more. Access to New Healthy Living Discounts Every Week Blue365 offers savings on nutrition programs, fitness accessories, and medical supplies and services like hearing aids and LASIK eye surgery. If you re a member, all you have to do is sign up for Blue365. Personal Dental Coverage Plan Benefits Include: Diagnostic and preventive services Restorative services Major restorative services, including crowns and onlays (12-month waiting period) * Endodontic services Periodontic services (12-month waiting period) * Removable and fixed prosthetics (12-month waiting period) * Specific oral surgical services Monthly Dental Premium: Your monthly premium is $27.50 for each adult and $20 for each dependent from age 2 through age 17. (Maximum charge would be for you, your spouse and up to three additional dependents per family. No charge for dependents ages 0-1.) Plan Features: Access to one of the largest PPO dental networks in the state, with 10 to 30 percent savings on dental services. Benefits paid based on a Maximum Allowable Charge (MAC), as specified in the Schedule of Benefits, up to an annual maximum of $1,000 per person once deductible has been met (if applicable). Orthodontia services, including braces, are not covered. Who Is Eligible for Coverage? Residents of Tennessee Dependent children 25 years old or less * 12-month waiting period applies to these services. This list is a summary of covered services. Complete coverage details are included in the policy.

3 Schedule of Benefits for Common Dental Procedures Procedure MAC ** Comprehensive oral evaluation $46 Periodic oral exam $30 Adult cleaning (preventive) $56 Child cleaning (preventive) $43 Bitewing X-ray (two films) $29 Filling (Amalgam-one surface) $38 Crown (porcelain fused to high noble metal) Root canal molar (excluding final restoration) Periodontal scaling and root planing (4+ teeth per quadrant) Non-surgical simple extraction single tooth $387 $340 $68 $47 Annual Deductible: Your deductible for the calendar year is $50 per person or $150 per family. The deductible doesn t apply to preventive and diagnostic services covered by your plan. Annual Maximum: Each member and each covered dependent has a $1,000 calendar year maximum. Limitations on Dental Services: Two exams in a 12-month period Two cleanings in a 12-month period X-rays: One complete and one panoramic in a 36-month period; one set of bitewings in a 12-month period (limited to four films) One fluoride treatment in a 12-month period (for children 17 and under) 12-month waiting periods apply to certain services (refer to your EOC) This is only a partial list; please see your policy for a complete Schedule of Benefits. How You Save Using a Network Dentist Many of the most common preventive and diagnostic services are covered at 100 percent when you see an in-network dentist. In this example, the dentist charges $80 for an adult cleaning (prophylaxis). This is considered preventive and the deductible does not apply. **Current MAC at time of printing, subject to change. Current Dental Terminology American Dental Association Network Dentist Dentist Charges Non-Network Dentist $80 $80 Provider Write-Off (i.e. Your Savings) $24 Network Allowance $56 Plan Pays (MAC) $56 $56 You Pay $0 $24

4 Optional Vision Coverage Personal VisionBlue See the advantages of adding VisionBlue to your coverage. VisionBlue benefits for you and your family can be a valuable addition to your personal dental plan. A comprehensive eye exam can lead to early detection of vision problems, as well as serious health conditions including cataracts, glaucoma, diabetes and hypertension. By adding VisionBlue coverage you can keep the routine vision needs of your family in focus with just one Member ID card for your wallet. Member Advantages Low monthly premiums Annual eye exams covered at a low copay from network providers Additional savings of up to 40 percent off retail price for frames and lenses Unlimited discounts after benefits have been used Quality network of providers including both private practice providers and retail chains Plans to Help You Save Money VisionBlue offers a choice of two plans. You can choose a lower cost plan that has a $10 copay on exams and discounts on materials at network providers, or an option including a $10 exam and $25 materials copay, with a $100 allowance for frames or contacts when using a network provider. Personal Vision Plan: Exam Only Exam Plus Materials $5.81 for each member enrolled $14.50 for each member enrolled Exclusions from Personal Dental Coverage This policy does not provide benefits for the following services, supplies or charges: Any procedure not listed in the Schedule of Benefits under Attachment C of the policy. Services or supplies that are determined to be not Necessary Dental Care or have not been authorized by BlueCross BlueShield of Tennessee. Any portion of a charge for any service in excess of the Maximum Allowable Charge. Overdentures and associated procedures. Cosmetic procedures. The replacement of full and partial dentures, bridges, inlays, onlays or crowns that can be repaired or restored to normal function. Dental implants. Removal of impacted teeth. Replacement of lost or stolen appliances or orthodontic retainers. Athletic mouth guards. Precision or semi-precision attachments. Denture duplication. Oral hygiene instructions. Plaque control. Completion of a claim form. Broken appointments. Prescription or take home fluoride. Diagnostic photographs. Services not completed by the end of the month in which coverage terminates. Procedures that are begun, but not completed. Services for which there would be no charge in the absence of insurance or for any service or treatment provided without charge. Services in connection with war or any act of war, whether declared or undeclared, or condition contracted or accident occurring while on full-time active duty in the armed forces of any country or combination of countries. Care or treatment of a condition for which the member is entitled to or eligible for benefits under any Worker s Compensation Act or similar law. Amounts applied toward the satisfaction of a deductible, if any. Services or supplies that are experimental or investigational in nature including but not limited to: (1) drugs, (2) biologicals; (3) medications; (4) devices; and (5) treatments. Services required because of illness or injury related to your commission of, or attempt to commit, a felony. Services or supplies for the treatment of work related illness or injury, regardless of the presence or absence of workers compensation coverage. This exclusion does not apply to injuries or illnesses resulting from self-employment. Services or supplies received before the member s effective date for coverage under this Policy. Telephone or consultations or charges for failure to keep a scheduled appointment or charges to complete a claim form or to provide medical records. Services for providing requested medical information or completing forms. BlueCross BlueShield of Tennessee will not charge for statutorily authorized copying charges. Charges in excess of the Maximum Allowable Charge for Covered Services or any charges which exceed the Lifetime Maximum. Any service stated in Attachment A as a non-covered Service or limitation. Charges for services performed by you or your spouse or your spouse s parent, sister, brother or child. Any charges for handling fees. Pharmaceuticals, drugs and drug compounds except as otherwise specified.

5 Notes BlueCross BlueShield of Tennessee (BlueCross) complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability or sex. BlueCross does not exclude people or treat them differently because of race, color, national origin, age, disability or sex. BlueCross: Provides free aids and services to people with disabilities to communicate effectively with us, such as: (1) qualified interpreters and (2) written information in other formats, such as large print, audio and accessible electronic formats. Provides free language services to people whose primary language is not English, such as: (1) qualified interpreters and (2) written information in other languages. If you need these services, contact a consumer advisor at the number on the back of your Member ID card or call (TTY: or 711). If you believe that BlueCross 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 ( Nondiscrimination Grievance ). For help with preparing and submitting your Nondiscrimination Grievance, contact a consumer advisor at the number on the back of your Member ID card or call (TTY: or 711). They can provide you with the appropriate form to use in submitting a Nondiscrimination Grievance. You can file a Nondiscrimination Grievance in person or by mail, fax or . Address your Nondiscrimination Grievance to: Nondiscrimination Compliance Coordinator; c/o Manager, Operations, Member Benefits Administration; 1 Cameron Hill Circle, Suite 0019, Chattanooga, TN ; (423) (fax); bcbst.com ( ). 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 hhs.gov/ocr/portal/lobby.jsf, 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, , (TDD). Complaint forms are available at BlueCross BlueShield of Tennessee, Inc., an Independent Licensee of the BlueCross BlueShield Association. BlueCross BlueShield of Tennessee is a Qualified Health Plan issuer in the Health Insurance Marketplace.

6 ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa (TTY: ). ध य न द : य द आप ह द ब लत ह त आपक लए म फ त म भ ष सह यत स व ए उपलब ध ह (TTY: ) पर क ल कर ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните (телетайп: ). توجه: اگر به زبان فارسی گفتگو می کنید تسهیالت زبانی بصورت رایگان برای شما فراهم می باشد. با (TTY: ) تماس بگیرید. ملحوظة: إذا كنت تتحدث اذكر اللغة فا ن خدمات المساعدة اللغویة تتوافر لك بالمجان. اتصل برقم (رقم ھاتف الصم والبكم: ). 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: ) CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số (TTY: ). 주의 : 한국어를사용하시는경우, 언어지원서비스를무료로이용하실수있습니다 (TTY: ) 번으로전화해주십시오. ATTENTION : Si vous parlez français, des services d aide linguistique vous sont proposés gratuitement. Appelez le (ATS : ). ໂປດຊາບ: ຖ າວ າ ທ ານເວ າພາສາ ລາວ,ການບ ລ ການຊ ວຍເຫ ອດ ານພາສາ, ໂດຍບ ເສ ຽຄ າ, ແມ ນມ ພ ອມໃຫ ທ ານ. ໂທຣ ማስታወሻ: የሚናገሩት ቋንቋ ኣማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች በነጻ ሊያግዝዎት ተዘጋጀተዋል ወደ ሚከተለው ቁጥር ይደውሉ (መስማት ለተሳናቸው: ). ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: સ ચન : જ તમ ગ જર ત બ લત હ, ત ન :શ લ ક ભ ષ સહ ય સ વ ઓ તમ ર મ ટ ઉપલબ ધ છ. ફ ન કર (TTY: ) 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 ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele (TTY: ). UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para ATTENZIONE: In caso la lingua parlata sia l italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero D77 baa ak0 n7n7zin: D77 saad bee y1n7[ti go Diné Bizaad, saad bee 1k1 1n7da 1wo d66, t 11 jiik eh, 47 n1 h0l=, koj8 h0d77lnih

7 Sign up for personal Dental coverage and VisionBlue. Call your agent or broker. 1 Cameron Hill Circle Chattanooga, TN bcbst.com COMM-537 (1/17) Standalone Personal Dental Brochure

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