Personal Blue DentalSM

Personal Blue Dental PlusSM

Individual dental plans from Blue Cross Blue Shield of Michigan

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Sink your teeth into total healthIt 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 BluesBlue DentalSM offers two individual dental plans that make getting your own dental coverage easy. Personal Blue DentalSM and Personal Blue Dental PlusSM 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.

Choose your plan

Select a dentist

Monthly premiums

Your benefits

Enrolling is easy

Application

Contents

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Choose your plan

Personal Blue DentalSM and Personal Blue Dental PlusSM offer the same quality benefits but different premiums and annual maximums, allowing you to choose the plan that best fits your budget.

Personal Blue DentalSM Personal Blue Dental PlusSM

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

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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 DentalSM Personal Blue Dental PlusSM

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 Blues-allowed amount** and the dentist’s charges, in addition to any deductible or copay.

Blue Par SelectSM 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 simpleYou can easily locate a PPO network or Blue Par Select dentist in your area at bcbsm.com/bluedental.

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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

Personal Blue Dental*(No out-of-network coverage) Personal Blue Dental Plus

In-Network 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 $1,250 per member for all covered services

$1,000 per member for all covered services

Deductible (Applied to basic and major restorative services; preventive services are not subject to the deductible.)

$50 single/$100 family (two or more people) per calendar year

Waiting period 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-raysCovered - 75%, one set every 24 months for Personal Blue Dental

Covered - 75%, one set every 12 months for Personal Blue Dental Plus

Full-mouth or panoramic X-rays Covered - 75%, full mouth series once every 60 months; panoramic X-ray 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

*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) Personal Blue Dental Plus

In-Network In-Network and Out-of-Network

Class II — Basic Restorative Services

Fillings – permanent teeth Covered – 50%, once every 48 months

Fillings – primary teeth Covered – 50%, once every 24 months

Onlays, crowns and veneer fillings – permanent teeth

Covered – 50%, once every 84 months per tooth, payable for members age 12 or older

Recementing of crowns, veneers, inlays, onlays and bridges

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

Periodontic maintenanceCovered – 50%, twice per calendar year, following surgical or non-surgical 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

Limited occlusal adjustments Covered – 50%, limited occlusal adjustments covered up to five times in a 60-month period

Occlusal biteguards Covered – 50%, one every 60 months

General anesthesia or IV sedation Covered – 50%, when medically necessary and performed with oral or dental surgery

Relining or rebasing of partials or complete dentures

Covered – 50%, once every 36 months per arch six months or more after initial delivery

Tissue conditioning Covered – 50%, once every 36 months per arch

Repair and adjustment of partial or complete dentures

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 16 or older

Covered – 50%, once every 60 months

Endosteal implants – for members age 16 or older who are covered at the time of the actual implant replacement

Covered – 50%, once per tooth in a member lifetime when implant placement is for teeth numbered 2 through 15 and 18 through 31

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.

Your benefits continued

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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.

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The information on this form and the following conditions are part of your contract with Blue Cross Blue Shield ofMichigan. Submit your completed application to:

You must provide proof of eligibility for coverage for you and your dependents when requested by BCBSM.

By sending notice, you authorize BCBSM to obtain hospital, medical and dental records about you and your familyfrom health care providers; and you authorize the release of any information needed to process or review a claim.

AuthorizationYou are responsible for notifying BCBSM of changes in you and your family's status that affect coverage such asmarriage, birth or the death of someone covered under the policy. Please send notice in writing to:

Blue Cross Blue Shield of Michigan - MC 609B600 E. Lafayette Blvd.Detroit, Michigan 48226-9942

Coverage effective datePersonal Blue Dental and Personal Blue Dental Plus coverage begins on a date determined by BCBSM. Youreffective date will be either the 1st or 15th of the month. If you apply for Blues health and dental coverage at thesame time, you will be given the same effective date for both plans. When your application is accepted, you andyour family are bound by the terms of the policy and this application.

Personal Blue Dental or Personal Blue Dental PlusBlue Cross Blue Shield of Michigan600 E. Lafayette Blvd. - MC 609BDetroit, MI 48226

You and your dependents must remain enrolled for a minimum of 12 months. If you terminate coverage for anyreason, you are not eligible to reapply for 12 months from the date of termination.

ApprovalYou will know your application has been accepted when you receive a bill from BCBSM. Please do not submitpayment until you receive a bill.

EligibilityTo be eligible for Personal Blue Dental and Personal Blue Dental Plus coverage:

ConfidentialityWe keep your personal health information confidential and do not release it without your consent or as permittedby state and federal privacy laws.

CF 10488 MAR 12

• You must have medical coverage• You must reside in Michigan at least six months of the year

Application for Individual Dental Coverage

Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.

Please read the following information before completing this application:

• 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

Family continuation coverageFamily continuation coverage provides for a dependent child if the child meets all of the following requirements:

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Your Last Name First Name M. I. Marital StatusS M

GenderM F

Requested Coverage Date (mm/dd/yyyy)

Street Address (can not be a P.O. Box) Zip Code CountyStateCity

Mailing Address (if different) Zip Code CountyStateCity

Social Security Number Phone Number

( )Drivers License NumberDate of Birth (mm/dd/yyyy) Issuing State

Email Address

Application for Individual Dental CoveragePrint 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 fi elds are required to be completed except where otherwise noted.

Part 1: Applicant Information

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

(mm/dd/yyyy) Gender

M FSocial Security Number

Drivers License Number Issuing State

Last Name (Child/Dependent) First Name M. I. Date of Birth (mm/dd/yyyy)

GenderM F

Social Security Number

Last Name (Child/Dependent) First Name M. I. Date of Birth (mm/dd/yyyy)

GenderM F

Social Security Number

Last Name (Child/Dependent) First Name M. I. Date of Birth (mm/dd/yyyy)

GenderM F

Social Security Number

If you wish to apply for coverage for an unmarried child who is age 19-25 this year, please complete below.(Please use an additional sheet of paper for more than one child.)

Drivers License Number Issuing State

Has anyone applying for coverage used tobacco products in the past 12 months? Yes NoIf yes who?Are you or any family members eligible for Medicare? Yes NoIf 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 NoCheck all that apply:

Carrier Contract NumberMedicare/Medicare Advantage

MedicaidNote: 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

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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

Automatic Payment (must be selected for monthly billing frequency)

Electronic Fund Transfer(EFT) Bill Me(available for quarterly only)

Please provide the following banking information:

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How do you want to want to make ongoing payments?

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.

Part 4: Signature

Please review your application for completeness and accuracy. Sign and date your application. If you areenrolling through an independent agent, submit your application directly to your agent so that he or she canprocess the application for you. If you are enrolling directly with BCBSM, please mail your completedapplication to:

Blue Cross Blue Shield of Michigan - MC 609B600 E. Lafayette Blvd.Detroit, Michigan 48226-9942

Signature of Applicant Date

I am applying for BCBSM Personal Blue Dental or Personal Blue Dental Plus coverage and am subject to theterms and conditions of this application. By signing this application, I agree that I and my covered dependentswill 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 torequirements by BCBSM for additional information and payment of bills. I certify that the requirements ofeligibility are met and that the information I have given on this application is true and correct to the best of myknowledge. I authorize BCBSM to obtain from providers of service any and all records relating to me and mycovered dependents and acknowledge that BCBSM has the right to use and disclose these records and otherconfidential member information for valid business purpose.

Signature of Spouse Date

Signature of Dependent (age 18 and over)

Signature of Dependent (age 18 and over) Date

Date

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Have questions? Visit bcbsm.com/myblue for information, or call 877-4MY-BLUE (877-469-2583) or your AuthorizedIndependent Agent for Blue Cross Blue Shield of Michigan.

Area below for Agent Use OnlyAgent Code MA/GA Code Agent Signature Date Signed (mm/dd/yy)

Assoc. /Chamber Code

Group # Service Code Eff. Date (mm/dd/yy) U/W

DEIDPre-existing Date (mm/dd/yyyy)

Area below for BCBSM Use Only

This option offers the convenience of making your first premium payment by credit card. Your coverage isassigned 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 isissued immediately, but coverage will not be activated until payment is received. Credit card payment can beused 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)

Credit Card Number Card Verification CodeCard Expiration Date

Cardholder Billing AddressStreet Address

State

Credit card payment cannot be processed without your signature. I authorize Blue Cross Blue Shield of Michiganto charge my credit card for my first health care premium payment amount. If at any time I decide to cancel thistransaction, I will notify Blue Cross Blue Shield of Michigan. I also understand that all information provided will remainconfidential.

City

Zip Code Daytime Phone Number

Signature Date

Social Security Number

Note: If you are submitting your application through an agent or by U.S. Mail and do not want your first premium payment paidby credit card, please remove this page before submitting the application.

Part 5: Credit Card Payment (for initial premium payment only)

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.

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Smile all the way to total healthRegular 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 Blues-contracted agent, call 1-877-4MY-BLUE (469-2583) or visit bcbsm.com/myblue.

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