Personal Blue Dental SM Personal Blue Dental Plus SM Individual dental plans from Blue Cross Blue Shield of Michigan

Personal Blue Dental SM Personal Blue Dental Plus SM Individual dental plans from Blue Cross Blue Shield of Michigan

Sink your teeth into total health It may surprise you to know that the condition of your mouth can reflect the condition of your overall health. In fact, your dentist may be the first health care professional to notice signs of health problems. Regular trips to your dentist can help you maintain good health. Quality dental care from the Blues Blue Dental SM offers two individual dental plans that make getting your own dental coverage easy. Personal Blue Dental SM and Personal Blue Dental Plus SM cover everything from routine cleanings and oral exams to fillings and crowns. Even better, both plans are backed by the value, experience and commitment of the Michigan Blues. Contents Choose your plan Select a dentist Monthly premiums Your benefits Enrolling is easy Application p2 p3 p4 p4 p6 p7 1

Choose your plan Personal Blue Dental SM and Personal Blue Dental Plus SM offer the same quality benefits but different premiums and annual maximums, allowing you to choose the plan that best fits your budget. Personal Blue Dental SM Personal Blue Dental Plus SM Gives you access to a large dental network Gives you the freedom to see any dentist Lower monthly premium Services by out-of-network dentists are covered Discounts on noncovered services with network dentists Discounts on noncovered services with network dentists Covers preventive, basic and major restorative services Covers preventive, basic and major restorative services 2

Selecting a dentist Personal Blue Dental and Personal Blue Dental Plus offer unparalleled access to dentists. Each plan gives you different options for finding the dentist of your choice. Personal Blue Dental SM Personal Blue Dental Plus SM This plan requires you to receive dental care from a PPO network* dentist. Network dentists provide a discount of 20 to 40 percent off their usual charge and a discount on noncovered services. Services received by out-of-network dentists are not covered by this plan. This plan gives you the freedom to choose any dentist. Network dentist or not you re covered. You have the following options when selecting a dentist: PPO network* dentists These dentists will always accept your coverage. Network dentists provide a 20 to 40 percent discount off their usual charge and a discount on noncovered services. You may also receive services from an out-of network dentist. If you do, you are responsible for the difference between the Bluesallowed amount** and the dentist s charges, in addition to any deductible or copay. Blue Par Select SM dentists These dentists agree to participate on a per claim basis. So before each procedure, ask whether your dentist participates. Almost all dentists participate with the Blues under this arrangement. *Blue Cross Blue Shield of Michigan uses Dental Network of America for its dental plans. Dental Network of America is an independent company. **The Blues maximum payment for a covered service. Finding a dentist is simple You can easily locate a PPO network or Blue Par Select dentist in your area at bcbsm.com/bluedental. 3

Monthly premiums and your benefits Number of members on your contract Personal Blue Dental Personal Blue Dental Plus Monthly Premium MI Claims Tax Assessment Total Monthly Amount*** Monthly Premium MI Claims Tax Assessment Total Monthly Amount*** One-person (single) $37.53 $0.28 $37.81 $44.09 $0.33 $44.42 Two-person $78.81 $0.59 $79.40 $92.58 $0.69 $93.27 Three or more (family) $116.34 $0.87 $117.21 $136.67 $1.03 $137.30 Family continuation** $18.77 $0.14 $18.91 $22.04 $0.17 $22.21 *Rates listed are in effect at the time of printing. **Family continuation provides coverage for dependents who meet certain age and support guidelines. ***These rates do not include upcoming federal taxes that will be added to your bill when they become effective. Personal Blue Dental* (No out-of-network coverage) In-Network Personal Blue Dental Plus In-Network and Out-of-Network Copays Class I Preventive services 25% 25% Class II Basic restorative services 50% 50% Class III Major restorative services 50% 50% Dollar maximums, deductibles and waiting period Annual maximum Deductible (Applied to basic and major restorative services; preventive services are not subject to the deductible.) Waiting period $1,250 per member for all covered services $1,000 per member for all covered services $50 single/$100 family (two or more people) per calendar year 6-month waiting period is applied on the effective date of dental coverage for basic and major restorative services; preventive services are not subject to a waiting period. Class I Preventive Services Oral exam Covered - 75%, two per calendar year Bitewing X-rays Covered - 75%, one set every 24 months for Personal Blue Dental Covered - 75%, one set every 12 months for Personal Blue Dental Plus Covered - 75%, full mouth series once every 60 months; panoramic X-ray Full-mouth or panoramic X-rays once every 84 months Prophylaxis (teeth cleaning) Covered - 75%, twice per calendar year Fluoride treatment Covered - 75%, once per calendar year through age 14 Space maintainers Covered - 75%, once per quadrant of the mouth per lifetime, under age 19 Palliative emergency treatment Covered - 75% Pit and fissure sealants for members age 16 or under Covered - 75%, once per tooth every 36 months when applied to the first and second permanent molars

Your benefits continued Personal Blue Dental* (No out-of-network coverage) In-Network Personal Blue Dental Plus In-Network and Out-of-Network Class II Basic Restorative Services Fillings permanent teeth Fillings primary teeth Onlays, crowns and veneer fillings permanent teeth Recementing of crowns, veneers, inlays, onlays and bridges Covered 50%, once every 48 months Covered 50%, once every 24 months Covered 50%, once every 84 months per tooth, payable for members age 12 or older Covered 50%, three times per tooth per calendar year after six months from original restoration Oral surgery including extractions Covered 50% Root canal treatment permanent tooth Covered 50%, once every 12 months for tooth with one or more canals Covered 50%, twice per calendar year, following surgical or non-surgical Periodontic maintenance treatment of periodontic disease. Each use of the periodontic maintenance benefit will replace prophylaxis available per year. Scaling and root planing Covered 50%, once every 36 months per quadrant of the mouth Covered 50%, limited occlusal adjustments covered up to five times in a Limited occlusal adjustments 60-month period Occlusal biteguards Covered 50%, one every 60 months Covered 50%, when medically necessary and performed with oral or General anesthesia or IV sedation dental surgery Relining or rebasing of partials or complete dentures Tissue conditioning Repair and adjustment of partial or complete dentures Covered 50%, once every 36 months per arch six months or more after initial delivery Covered 50%, once every 36 months per arch Covered Included in fee for a new denture or partial within six months of initial delivery. After six months covered at 50%. Class III Major Restorative Services Removable dentures (complete and partial) Covered 50%, once every 60 months Bridges (fixed partial dentures) for members age Covered 50%, once every 60 months 16 or older Endosteal implants for members age 16 or Covered 50%, once per tooth in a member lifetime when implant older who are covered at the time of the actual placement is for teeth numbered 2 through 15 and 18 through 31 implant replacement Class IV Orthodontic Services are not covered by these plans. This is intended as a summary. It is not a contract. Additional limitations and exclusions may apply to covered services. For a complete description of benefits, please see the applicable Blue Cross Blue Shield of Michigan certificates and riders. Payment amounts are based on the Blue Cross Blue Shield of Michigan approved amount or the fee negotiated for this program, less any applicable deductible and/or copay amounts required by your plan. This coverage is provided pursuant to a contract entered into in the state of Michigan and will be construed under the jurisdiction of and according to the laws of the state of Michigan. Note: For non-urgent, complex or expensive dental treatment such as crowns, bridges or dentures, members should encourage their dentist to submit the claim to Blue Cross for predetermination before treatment begins. Personal Blue Dental members: if you receive care from a non-network dentist, you will be billed for the entire charge. Personal Blue Dental Plus members: if you receive care from a nonparticipating dentist, you may be billed for the difference between our approved amount and the dentist s charge. 5

Enrolling is easy Want to sign up for Personal Blue Dental or Personal Blue Dental Plus coverage? It s simple. Choose the method that works best for you: Online: bcbsm.com/myblue Phone: 1-877-4MY-BLUE (469-2583) Mail: Send the enclosed application to: Blue Cross Blue Shield of Michigan MC 609B 600 E. Lafayette Blvd. Detroit, Michigan 48226-9942 You can also contact a Blues-contracted agent. 6

Application for Individual Dental Coverage Please read the following information before completing this application: The information on this form and the following conditions are part of your contract with Blue Cross Blue Shield of Michigan. Submit your completed application to: Blue Cross Blue Shield of Michigan - MC 609B 600 E. Lafayette Blvd. Detroit, Michigan 48226-9942 Coverage effective date Personal Blue DentalSM and Personal Blue Dental PlusSMcoverage begins on a date determined by BCBSM. Your effective date will be either the 1st or 15th of the month. If you apply for Blues health and dental coverage at the same time, you will be given the same effective date for both plans. When your application is accepted, you and your family are bound by the terms of the policy and this application. You and your dependents must remain enrolled for a minimum of 12 months. If you terminate coverage for any reason, you are not eligible to reapply for 12 months from the date of termination. Approval You will know your application has been accepted when you receive a bill from BCBSM. Please do not submit payment until you receive a bill. Authorization You are responsible for notifying BCBSM of changes in you and your family's status that affect coverage such as marriage, birth or the death of someone covered under the policy. Please send notice in writing to: Personal Blue Dental or Personal Blue Dental Plus Blue Cross Blue Shield of Michigan 600 E. Lafayette Blvd. - MC 609B Detroit, MI 48226 By sending notice, you authorize BCBSM to obtain hospital, medical and dental records about you and your family from health care providers; and you authorize the release of any information needed to process or review a claim. Confidentiality We keep your personal health information confidential and do not release it without your consent or as permitted by state and federal privacy laws. Eligibility To be eligible for Personal Blue Dental and Personal Blue Dental Plus coverage: You must have medical coverage You must reside in Michigan at least six months of the year You must provide proof of eligibility for coverage for you and your dependents when requested by BCBSM. Family continuation coverage Family continuation coverage provides for a dependent child if the child meets all of the following requirements: Between the ages 19 and 25 Unmarried A member of your household (unless temporarily residing elsewhere, such as college students living away at school) You provide more than half of the child's support Related to you by blood, marriage, legal adoption or legal guardianship A full-time student for a minimum of five months of the year OR has gross income of less than four times the personal exemption amount identified in the Internal Revenue Service Gross Income Test CF 10488 MAR 12 Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association. Page 1 of 5

Application for Individual Dental Coverage Print in black or blue ink or type your information. Review your application for completeness and accuracy, and sign and date the application where requested. All fields are required to be completed except where otherwise noted. Part 1: Applicant Information Your Last Name First Name M. I. Marital Status S M Gender M Street Address (can not be a P.O. Box) City State Zip Code County F Requested Coverage Date (mm/dd/yyyy) Mailing Address (if different) City State Zip Code County Social Security Number Email Address Phone Number ( ) Date of Birth (mm/dd/yyyy) Drivers License Number Issuing State If you wish to apply for coverage for a spouse or unmarried children underage 19, please list them below. (Please use an additional sheet of paper for more than two children.) Last Name (Spouse) First Name M. I. Date of Birth Gender Social Security Number (mm/dd/yyyy) M F Drivers License Number Issuing State Last Name (Child/Dependent) First Name M. I. Date of Birth (mm/dd/yyyy) Last Name (Child/Dependent) First Name M. I. Date of Birth (mm/dd/yyyy) (Please use an additional sheet of paper for more than one child.) Last Name (Child/Dependent) First Name M. I. Date of Birth (mm/dd/yyyy) Gender M Gender M If you wish to apply for coverage for an unmarried child who is age 19-25 this year, please complete below. Drivers License Number Issuing State Gender M F F F Social Security Number Social Security Number Social Security Number Has anyone applying for coverage used tobacco products in the past 12 months? Yes No If yes who? Are you or any family members eligible for Medicare? Yes No If yes who? 1. I live in Michigan six or more months each year : Yes No 2. Are you or your family members applying for coverage currently active under a Blue Cross Blue Shield of Michigan health plan? Yes No If yes, please provide your : Contract Number Group Number 3. Are you covered under another health insurance carrier? Yes No Check all that apply: Carrier Medicare/Medicare Advantage Contract Number Medicaid Note: To be eligible for this coverage you must be enrolled in a medical plan. 4. Are you currently enrolled in another dental program? Yes No Termination Date *The requested effective date must be a future date and either the 1st or 15th of the month. See the Coverage effective date section on page1 of this application for more information. Blue Cross Blue Shield of Michigan is a nonprof t corporation and independent licensee oft he Blue Cross and Blue Shield Association. CF 10488 MAR 12 Page 2 of 5

Part 3: Payment Options How do you want to pay your initial premium? Bill Me Electronic Fund Transfer (EFT) Credit Card (please complete page 5 of this application) Please select a billing frequency for future payments: Monthly(must be automatic payment) Quarterly How do you want to want to make ongoing payments? Electronic Fund Transfer(EFT) Bill Me(available for quarterly only) Automatic Payment (must be selected for monthly billing frequency) Please provide the following banking information: S E D

Part 4: Signature Please review your application for completeness and accuracy. Sign and date your application. If you are enrolling through an independent agent, submit your application directly to your agent so that he or she can process the application for you. If you are enrolling directly with BCBSM, please mail your completed application to: Blue Cross Blue Shield of Michigan - MC 609B 600 E. Lafayette Blvd. Detroit, Michigan 48226-9942 I am applying for BCBSM Personal Blue Dental or Personal Blue Dental Plus coverage and am subject to the terms and conditions of this application. By signing this application, I agree that I and my covered dependents will be bound by all of the BCBSM Personal Blue Dental or Personal Blue Dental Plus benefit requirements. Approval of this application and coverage effective date will be determined by BCBSM and shall be subject to requirements by BCBSM for additional information and payment of bills. I certify that the requirements of eligibility are met and that the information I have given on this application is true and correct to the best of my knowledge. I authorize BCBSM to obtain from providers of service any and all records relating to me and my covered dependents and acknowledge that BCBSM has the right to use and disclose these records and other confidential member information for valid business purpose. Signature of Applicant Date Signature of Spouse Date Signature of Dependent (age 18 and over) Date Signature of Dependent (age 18 and over) Date Have questions? Visit bcbsm.com/myblue for information, or call 877-4MY-BLUE (877-469-2583) or your Authorized Independent Agent for Blue Cross Blue Shield of Michigan. Area below for Agent Use Only Agent Code MA/GA Code Agent Signature Date Signed (mm/dd/yy) Assoc. /Chamber Code Area below for BCBSM Use Only Group # Service Code Eff. Date (mm/dd/yy) U/W Pre-existing Date (mm/dd/yyyy) DEID CF 10488 MAR 12 Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association. Page 4 of 5

Part 5: Credit Card Payment (for initial premium payment only) Note: If you are submitting your application through an agent or by U.S. Mail and do not want your first premium payment paid by credit card, please remove this page before submitting the application. This option offers the convenience of making your first premium payment by credit card. Your coverage is assigned an effective date upon Underwriting approval, but it is not active until payment is received by BCBSM. Using a credit card to pay your premium will activate your coverage more quickly. Your Identification Card is issued immediately, but coverage will not be activated until payment is received. Credit card payment can be used for your initial premium payment only. Credit Card Type VISA MasterCard How do you want to make ongoing payments? Bill me Automatic payment from my bank account (To enroll, complete the automatic payment section on page 3.) Cardholder s Name (exactly as it appears on the card) Social Security Number Credit Card Number Card Expiration Date Card Verification Code Cardholder Billing Address Street Address City State Zip Code Daytime Phone Number Credit card payment cannot be processed without your signature. I authorize Blue Cross Blue Shield of Michigan to charge my credit card for my first health care premium payment amount. If at any time I decide to cancel this transaction, I will notify Blue Cross Blue Shield of Michigan. I also understand that all information provided will remain confidential. Signature Date Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association. CF 10488 MAR 12 Page 5 of 5

Smile all the way to total health Regular trips to the dentist can add up to better overall health for you and your family. For more information about Personal Blue Dental or Personal Blue Dental Plus, contact a Bluescontracted agent, call 1-877-4MY-BLUE (469-2583) or visit bcbsm.com/myblue. 13

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