Blue Cross of Idaho District Offices

BOISE OFFICE3000 E. Pine Ave.

Meridian, ID 83642-5995Mailing AddressP.O. Box 7408

Boise, ID 83707-1408(208) 387-6683

COEUR D’ALENE OFFICE1900 Northwest Boulevard, Suite 109

Coeur d’Alene, ID 83814(208) 666-1495

IDAHO FALLS OFFICE2116 East 25th Street

Mailing AddressP.O. Box 2287

Idaho Falls, ID 83403(208) 522-8813

LEWISTON OFFICE1010 17th StreetMailing AddressP.O. Box 1468

Lewiston, ID 83501(208) 746-0531

POCATELLO OFFICE270 McKinley Ave., Suite B

Pocatello, ID 83201Mailing AddressP.O. Box 2578

Pocatello, ID 83206(208) 232-6206

TWIN FALLS OFFICE1431 N. Fillmore St., Suite 200

Twin Falls, ID 83301Mailing AddressP.O. Box 5025

Twin Falls, ID 83303(208) 733-7258

www.bcidaho.com

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.

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:

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

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

• Rendered prior to your effective date of coverage; or

• Not prescribed by a dental care provider.For a complete list of exclusions and limitations, please see the policy.

Form No. 15-009 (05-06)

Policy Form # 3-390-1000-08/033-390-1500-08/03

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.

Dental Blue® PPOAn Individual Stand-alone

Dental Program

Pa

ym

ent O

ptio

ns (1st m

onth

s prem

ium

required

with

ap

plica

tion – N

o $2 service fee required

on first m

onth

)

❐ A

utomatic m

onthly bank withdraw

al (complete authorization below

) ❐

Monthly – direct coupon (paym

ent must include $2 m

onthly service fee)

Au

tho

riza

tion

Ag

reemen

t for B

an

k W

ithd

raw

al

I or we, m

eaning my spouse if applicable, authorize and

request 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

assumes full responsibility for correctly inform

ing the bank of the specific am

ount of each deduction. I or we m

ay termi-

nate this agreement at any tim

e by notifying BC

I or the bank in w

riting. Termination w

ill take effect after BC

I or the bank has received the w

ritten notice and had a reasonable amount

of time to act on it.

Bank N

ame _________________________________________________________________

Bank A

ddress (city, state) _______________________________________________________

Custom

er Bank A

ccount No. _____________________

Com

pany I.D. N

o. 0000500005

Signed _____________________________________________

Date _________________

Signed _____________________________________________

Date _________________

Transit R

outing No.

Account N

umber

Please attach

void

ed ch

eck for au

tom

atic ban

k with

draw

al.

Sta

temen

t of U

nd

erstan

din

g

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 com

pletely 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 facsim

ile 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 material 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 paym

ent submitted w

ith this application w

ill be refunded. Upon the refund of the paym

ent, Blue C

ross of Idaho will have no

further obligations to me or any fam

ily mem

ber listed on this application.• If this application is approved, coverage for m

yself and any eligible family m

embers

named on this application w

ill begin on the date assigned by Blue C

ross of Idaho.• If this application is approved, I understand a copy of the application w

ill be attached to m

y policy. I approve the inclusion of any needed alterations to the application as long as I have been consulted by a duly authorized em

ployee of Blue

Cross of Idaho or a licensed and duly appointed Independent Producer representing

me, and I have had an opportunity to review

the application that will 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 th

at I have review

ed all an

swers g

iven o

n th

is app

lication

and

, if an

ind

epen

den

t pro

du

cer or o

ther p

erson

has filled

ou

t the an

swers fo

r m

e, I verify that th

e answ

ers are true an

d co

mp

lete. I un

derstan

d th

at this

app

lication

is a legal d

ocu

men

t and

will b

ecom

e part o

f the co

ntract b

etween

B

lue C

ross o

f Idah

o an

d th

e enro

llee.

X___________________________________________

________________ A

pplicant’s Signature

D

ate (P

arent or Guardian's signature if applicant is under age 18)

X___________________________________________

________________ S

pouse’s Signature (if listed on application)

D

ate

Fo

r Ind

epen

den

t Pro

du

cers On

ly

Ind

epen

den

t Pro

du

cer Ch

ecklist

❒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 paperw

ork 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?❒A

re all payments attached to the front of the application?

❒If one check is w

ritten for split applications, is a breakdown of am

ounts that apply to each application included?

Ind

epen

den

t Pro

du

cer Certificatio

n

1. W

ho actually completed this application?

❒ A

pplicant ❒

Independent Producer ❒

Other

If Independent Producer or O

ther, please explain ______________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________________________

2. W

ere you present at the time the application w

as filled out? ❒

Ye

S

❒ n

o

If n

o, please explain ________________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________________________

3. W

as money collected from

the applicant? ❒

Ye

S

❒ n

o a

mo

un

t $ __________________________________________________________________________________

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

material 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

Please recycle

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

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 BenefitsMajor 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.

Dental Blue® PPO – An Individual Dental Program

(continued)

1Basic care services have a six-month waiting period2Major care services have a 12-month waiting period3Deductible applies to out-of-network preventive services, and in- or out-of-network basic and major services

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

de

nta

l b

lu

e® p

po

in

div

idu

al

en

ro

ll

me

nt

ap

pl

ica

tio

n

Ap

pli

can

t In

form

ati

on

(A

pp

lica

nts

age

65

an

d o

lder

are

not

eli

gib

le)

Your

Nam

e (f

irst

, in

itia

l, la

st)

Dat

e of

Birt

h (m

m/d

d/y

y)So

cial

Sec

urity

Num

ber

Bus

ines

s Ph

one

Hom

e Ph

one

Mai

ling

Add

ress

(str

eet

or r

oute

)C

ity, S

tate

, Zip

Cod

eC

ount

y

Bill

ing

Add

ress

(if

diffe

rent

fro

m m

ailin

g ad

dres

s)C

ity, S

tate

, Zip

Cod

eC

ount

y

Nam

e of

Em

ploy

erYo

ur O

ccup

atio

nId

aho

resi

dent

? q

Yes

q N

oIf

yes,

how

long

? _

____

___

Mar

ital S

tatu

s: ❒

Sin

gle

❒

Mar

ried

❒ D

ivor

ced

❒ W

idow

ed❒M

ale

❒ F

emal

e

Pro

gra

m I

nfo

rma

tio

n

❒ D

enta

l Blu

e 10

00 (

$1,0

00 B

enef

it Pe

riod

Max

)

(six

-mon

th w

aitin

g pe

riod

for

basi

c ca

re/1

2-m

onth

wai

ting

perio

d fo

r m

ajor

car

e)❒

Den

tal B

lue

1500

($1

,500

Ben

efit

Perio

d M

ax)

req

ues

ted

eff

ecti

ve d

ate

/

/

(Ear

liest

effe

ctiv

e da

te w

ill b

e th

e 1s

t of

the

mon

th fo

llow

ing

appr

oval

.)

Oth

er C

ov

era

ge

Info

rma

tio

n

Is a

ny p

erso

n lis

ted

on th

is a

pplic

atio

n no

w c

over

ed o

r ha

s he

or

she

been

cov

ered

by

any

kind

of d

enta

l ins

uran

ce ?

❒

Ye

S

❒ n

o

If Y

eS

:

Nam

e(s)

of o

ther

den

tal i

nsur

ance

car

rier(

s) _

____

____

____

____

____

____

____

____

____

____

____

____

_ Po

licy

num

ber(

s) _

____

____

____

____

____

____

_

City

/Sta

te _

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

__

____

____

____

____

____

____

Pers

on(s

) co

vere

d un

der

the

polic

y __

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

Is a

ny p

erso

n on

the

appl

icat

ion

cove

red

by a

med

ical

hea

lth in

sura

nce

polic

y?

App

lican

t q

YES

q

NO

F

amily

Mem

ber

q Y

ES

qN

O

Ch

an

ge

Req

ues

t

Cha

nge

curr

ent e

nrol

lmen

t bec

ause

of:

❒

Mar

riage

❒

Div

orce

❒

Birt

h ❒

Dea

th

❒ C

ourt

Ord

er (c

opy

requ

ired)

❒

Oth

er

Dat

e of

eve

nt

/

/ A

dd

itio

na

l F

am

ily

Mem

ber

In

form

ati

on

(F

am

ily

mem

bers

age

65

an

d o

lder

are

not

eli

gib

le)

List

add

ition

al e

nrol

ling

fam

ily m

embe

rs in

clud

ing

any

unm

arrie

d ch

ild w

ho is

und

er a

ge 1

9; o

r who

is u

nder

age

23

and

a fu

ll-tim

e st

uden

t and

fina

ncia

lly

depe

nden

t upo

n yo

u; o

r w

ho is

med

ical

ly c

ertif

ied

as d

isab

led

and

depe

nden

t upo

n yo

u fo

r su

ppor

t (co

py o

f cer

tific

atio

n re

quire

d).

Fam

ily M

embe

r’s N

ame

(fir

st,

initi

al,

last

)R

elat

ions

hip

to A

pplic

ant

(sp

ou

se,

child

, st

ep

child

, e

tc.)

Dat

e of

Birt

h (m

m/d

d/y

y)A

ge❒M

ale

❒ F

emal

e

Fam

ily M

embe

r’s N

ame

(fir

st,

initi

al,

last

)D

ate

of B

irth

(mm

/dd

/yy)

Age

❒M

ale

❒ F

emal

e

Fam

ily M

embe

r’s N

ame

(fir

st,

initi

al,

last

)D

ate

of B

irth

(mm

/dd

/yy)

Age

❒M

ale

❒ F

emal

e

Fam

ily M

embe

r’s N

ame

(fir

st,

initi

al,

last

)D

ate

of B

irth

(mm

/dd

/yy)

Age

❒M

ale

❒ F

emal

e

Fam

ily M

embe

r’s N

ame

(fir

st,

initi

al,

last

)D

ate

of B

irth

(mm

/dd

/yy)

Age

❒M

ale

❒ F

emal

e

Pa

ren

tal

or

Gu

ard

ian

Co

nse

nt

to A

pp

lica

tio

n (

On

ly i

f a

pp

lica

nt

is u

nd

er a

ge 1

8)

I re

pres

ent

that

the

per

son

liste

d as

the

app

lican

t on

thi

s ap

plic

atio

n is

und

er 1

8 ye

ars

of a

ge a

nd is

app

lyin

g fo

r B

lue

Cro

ss o

f Id

aho

heal

th c

over

age

with

my

full

know

ledg

e an

d co

nsen

t. I

acc

ept

full

resp

onsi

bilit

y fo

r th

e pa

ymen

t of

pre

miu

ms

and

the

info

rmat

ion

prov

ided

on

this

app

licat

ion.

Sign

atur

ePr

int N

ame

Dat

e

Ind

ep

en

de

nt

Pro

du

cer’

s N

am

e _

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

___

BC

I __

____

____

____

____

___

Off

ice

Use

On

ly

Prog

ram

No.

Enro

llee

IDEf

fect

ive

Dat

eC

lass

Plan

Rea

son

Cod

eB

ill M

ode

Paym

ent R

ecei

ved

Rec

eipt

IDA

udito

r

Str

eet

Add

ress

: 300

0 E.

Pin

e A

ve.,

Mer

idia

n, ID

836

42-5

995

• M

ailin

g A

ddre

ss: P

.O. B

ox 7

408,

Boi

se, I

D 8

3707

-140

8 •

(208

) 34

5-45

50

For

m N

o. 1

5-00

8 (0

5-06

)

/

/

/

/

/

/

/

/

/

/

/

/

/

/