A VoluntaryDentalPlan

Proposalfor

Date:

AboutBlueCrossand BlueShieldofNorth Carolina

BlueCrossandBlueShieldofNorthCarolina(BCBSNC)isaleaderindeliveringinnovativehealthcareproducts,servicesandinformationtonearly3.4millionmembers,including744,000servedonbehalfofotherBlueCrossandBlueShieldPlans.Forover80years,thecompanyhasserveditscustomersbyofferingaccesstoqualityhealthcareatacompetitivepriceandhasservedthepeopleofNorthCarolinathroughsupportofcommunityorganizations,programsandeventsthatpromotegoodhealth.

Dental BlueSelectSM OVERVIEW

DentalBlueSelectisaVoluntaryDentalplanunderwrittenbyBlueCrossandBlueShieldofNorthCarolina.

BENEFIT HIGHLIGHTS:

  • Nonetworklimitations–Freedomtochooseanydentist
  • $100Lifetimedeductiblefeature
  • Availabletogroupsize5andabove(CompleteEnhancedPlans),groupsize10andabove(Standard)
  • Nowaitingperiodforpreventiveanddiagnosticservices
  • Nounderwritingrequired
  • NochargeforeBenefitsNowwhenalsoenrolledwithBCBSNCMedical
  • PriorCoverageCreditavailableonCompleteandEnhancedPlans
  • Easypaymentthroughpayrolldeduction
  • Flexiblefundingplan–premiumsmaybeeitherfullyfundedbyemployeesorincludeemployercontribution

THREECOVERAGEPLANS TO CHOOSEFROM:

DENTALBLUESELECToffersthreecoverageplans:

1.Standard–lowcostoptionforpriceconsciencecustomers

2.Complete–coversallofyourdentalneeds,orthodontiacoverageisoptional

3.Enhanced–qualitycoverageatagreatvalue,orthodontiacoverageisoptionalThenextpageprovidesacoverageplancomparison.

DentalBlueSelectSM PLANCOMPARISON

FEATURES / Standard / Complete(Orthodontiaoptional) / Enhanced(Orthodontiaoptional)
Diagnostic PreventiveCoverage (100%) / -Routine exams/cleaning(1per benefitperiod)
-Bitewing X-rays
(1per benefitperiod)
-Fluoride Treatment
(1per benefitperiod,childrenunder age 19)
-Emergency treatmentforpain
-Sealants forchildrenages6through15 / -Routine exams/cleaning(2per benefitperiod)
-Bitewing X-rays
(1per benefitperiod)
-Fluoride Treatment
(1per benefitperiod,childrenunder age 19)
-Emergency treatmentforpain
-Sealants forchildrenages6through15 / -Routine exams/cleaning(2per benefitperiod)
-Bitewing X-rays
(1per benefitperiod)
-Fluoride Treatment
(1per benefitperiod,childrenunder age 19)
-Emergency treatmentforpain
-Sealants forchildrenages6through15
Basic Coverage (80%)
Standardor CompletePlan:
6monthwaitingperiod
Enhanced(withorwithout Orthodontia):Nowaitingperiod / -Simple restorative services
-Simple teethremoval / -Simple restorative services
-Simple teethremoval / -Simple restorative services
-Simple teethremoval
-PeriapicalX-rays
-FullmouthX-rays(1per 36 months)
-Endodontics
-Periodontics
Major Coverage (50%)
12monthwaitingperiodall plans / -Endodontics
-Periodontics
-Surgicalteethremovaloralsurgery
-Anesthesia
-Spacemaintainers
-X-rays of the roots
-FullmouthX-rays(1per 36 months) / -PeriapicalX-rays
-FullmouthX-rays(1per 36 months)
-Endodontics
-Periodontics
-Surgicalteethremovaloralsurgery
-Anesthesia
-Spacemaintainers
-Major restorative services
-Prosthodontics
-Denture relines
-Recementationsand repairof crowns,inlays,bridgesanddentures / -Surgicalteethremovaloralsurgery
-Anesthesia
-Spacemaintainers
-Major restorative services
-Dentalimplants
-Prosthodontics
-Denture relines
-Recementationsand repairof crowns,inlays,bridgesanddentures
OptionalOrthodontiaCoverage
12monthwaitingperiod / Notavailable / -No deductible
-50%Coverage
-LifetimeMaximum*Available options:$1,000or
$1,500
-Childrenunderage 19 / -No deductible
-50%Coverage
-LifetimeMaximum*Available options:$1,000or
$1,500
-Childrenunderage 19

*TheLifetimeMaximumamountselectedforOrthodontiacoveragemustbeconsistentwiththeMaximumContractYearBenefitAmount.

NOTE:Memberswhocandemonstrateproofofpriordentalcoveragemayhavetheirwaitingperiodswaivedorreduced.ProofofpriorcoverageincludesabillorCertificateofCreditableCoveragefromthepriorcarrier.(CompleteandEnhancedPlansonly)

STANDARDPLANOPTION

Eligibility/Participation:Atleast20%ofeligibleemployeeswithaminimumof10employeesLifetimeDeductible:$100perperson(allservices)

PriorCoverageCredit:No

MaximumContractYearBenefit:$1,000

DIAGNOSTICPREVENTIVESERVICES:100%Coverage
Nowaitingperiod
  • Routineexams(onceperbenefitperiod)
  • Cleanings:prophylaxis,includingscalingandpolishingabovethegumline(onceperbenefitperiod)
  • Pulp-testing:evaluationoftoothnerve(limitedto1chargepervisit)
  • BitewingX-rays(onceperbenefitperiod)
  • Topicalfluorideapplicationforchildrenunderage19(onceperbenefitperiod)
  • Emergencytreatmentforpain
  • Sealantsforchildrenages6-15(onereapplicationpertoothevery5years)
BASICSERVICES:80%Coverage
6MonthWaitingPeriod
  • RoutineFillings
  • Simpleextractions
MAJORSERVICES:50%Coverage
12MonthWaitingPeriod
  • Endodonticsincludingrootcanal:Treatmentofthenervechamberandcanals
  • Periodontics:Treatmentofthediseaseofthegumsandbonesurroundingteeth
  • SpaceMaintainersforchildrenthroughage15
  • Surgicalteethremovalandoralsurgery
  • Anesthesiawhenclinicallynecessaryandrelatedtocoveredsurgery
  • PeriapicalX-rayoftherootsofteeth
  • FullmouthX-ray(oneevery36monthsunlesstakenforcovereddiagnosis)
PRE-TREATMENTESTIMATEOFBENEFITS:

Asaservicetoprotectmembers,whenchargesfromadentistforaproposedcourseoftreatmentareexpectedtobeover$250,apre-treatmentestimateofbenefitsisstronglyrecommendedbeforeanyservicesareperformed.

COMPLETEPLANOPTION

Eligibility/Participation:Atleast20%ofeligibleemployeeswithaminimumof5employeesLifetimeDeductible:$100perperson(allservices)

PriorCoverageCredit:Yes

MaximumContractYearBenefit:$1,000or$1,500

DIAGNOSTICPREVENTIVESERVICES:100%Coverage
Nowaitingperiod
  • Routineexams(twiceperbenefitperiod)
  • Cleanings:prophylaxis,includingscalingandpolishingabovethegumline(twiceperbenefitperiod)
  • Pulp-testing:evaluationoftoothnerve(limitedto1chargepervisit)
  • BitewingX-rays(onceperbenefitperiod)
  • Topicalfluorideapplicationforchildrenunderage19(onceperbenefitperiod)
  • Emergencytreatmentforpain
  • Sealantsforchildrenages6-15(onereapplicationpertoothevery5years)
BASICSERVICES:80%Coverage
6MonthWaitingPeriod
  • RoutineFillings
  • Simpleextractions
MAJORSERVICES:50%Coverage
12MonthWaitingPeriod
  • Endodonticsincludingrootcanal:Treatmentofthenervechamberandcanals
  • Periodontics:Treatmentofthediseaseofthegumsandbonesurroundingteeth
  • PeriapicalX-rayoftherootsofteeth
  • FullmouthX-ray(oneevery36monthsunlesstakenforcovereddiagnosis)
  • SpaceMaintainersforchildrenthroughage15
  • Surgicalteethremovalandoralsurgery
  • Anesthesiawhenclinicallynecessaryandrelatedtocoveredsurgery
  • Majorrestorativeservicesincludingcrowns,inlays,andonlays
  • Prosthodontics:Fullandpartialdentures,bridges
  • Fixedbridgeanddenturerepairs
  • Recementingofinlays,crowns,and/orbridges
PRE-TREATMENTESTIMATEOFBENEFITS:

Asaservicetoprotectmembers,whenchargesfromadentistforaproposedcourseoftreatmentareexpectedtobeover$250,apre-treatmentestimateofbenefitsisstronglyrecommendedbeforeanyservicesareperformed.

COMPLETEPLANOPTIONWITHORTHODONTIA

SAMEBENEFITSASTHECOMPLETEPLAN,PLUSORTHODONITIACOVERAGE

Eligibility/Participation:Atleast20%ofeligibleemployeeswithaminimumof5employeesLifetimeDeductible:$100perperson(allservices,exceptOrthodontia)

PriorCoverageCredit:Yes

MaximumContractYearBenefit:$1,000or$1,500

ORTHODONTIA:

-Nodeductible

-$1,000or$1,500LifetimeMaximum(mustbeconsistentwithmaximumcontractyearbenefitabove)

-Childrenunderage19only

DIAGNOSTICPREVENTIVESERVICES:100%Coverage
Nowaitingperiod
  • Routineexams(twiceperbenefitperiod)
  • Cleanings:prophylaxis,includingscalingandpolishingabovethegumline(twiceperbenefitperiod)
  • Pulp-testing:evaluationoftoothnerve(limitedto1chargepervisit)
  • BitewingX-rays(onceperbenefitperiod)
  • Topicalfluorideapplicationforchildrenunderage19(onceperbenefitperiod)
  • Emergencytreatmentforpain
  • Sealantsforchildrenages6-15(onereapplicationpertoothevery5years)
BASICSERVICES:80%Coverage
6MonthWaitingPeriod
  • RoutineFillings
  • Simpleextractions
MAJORSERVICES:50%Coverage
12MonthWaitingPeriod
  • Endodonticsincludingrootcanal:Treatmentofthenervechamberandcanals
  • Periodontics:Treatmentofthediseaseofthegumsandbonesurroundingteeth
  • PeriapicalX-rayoftherootsofteeth
  • FullmouthX-ray(oneevery36monthsunlesstakenforcovereddiagnosis)
  • SpaceMaintainersforchildrenthroughage15
  • Surgicalteethremovalandoralsurgery
  • Anesthesiawhenclinicallynecessaryandrelatedtocoveredsurgery
  • Majorrestorativeservicesincludingcrowns,inlays,andonlays
PRE-TREATMENTESTIMATEOFBENEFITS:

Asaservicetoprotectmembers,whenchargesfromadentistforaproposedcourseoftreatmentareexpectedtobeover$250,apre-treatmentestimateofbenefitsisstronglyrecommendedbeforeanyservicesareperformed.

ENHANCEDPLANOPTION

Eligibility/Participation:Atleast20%ofeligibleemployeeswithaminimumof5employeesLifetimeDeductible:$100perperson(allservices)

PriorCoverageCredit:Yes

MaximumContractYearBenefit:$1,000or$1,500

DIAGNOSTICPREVENTIVESERVICES:100%Coverage
Nowaitingperiod
  • Routineexams(twiceperbenefitperiod)
  • Cleanings:prophylaxis,includingscalingandpolishingabovethegumline(twiceperbenefitperiod)
  • Pulp-testing:evaluationoftoothnerve(limitedto1chargepervisit)
  • BitewingX-rays(onceperbenefitperiod)
  • Topicalfluorideapplicationforchildrenunderage19(onceperbenefitperiod)
  • Emergencytreatmentforpain
  • Sealantsforchildrenages6-15(onereapplicationpertoothevery5years)

BASICSERVICES:80%Coverage

NoWaitingPeriod
  • RoutineFillings
  • Simpleextractions
  • Endodonticsincludingrootcanal:Treatmentofthenervechamberandcanals
  • Periodontics:Treatmentofthediseaseofthegumsandbonesurroundingteeth
  • PeriapicalX-rayoftherootsofteeth
  • FullmouthX-ray(oneevery36monthsunlesstakenforcovereddiagnosis)

MAJORSERVICES:50%Coverage

12MonthWaitingPeriod
  • SpaceMaintainersforchildrenthroughage15
  • Surgicalteethremovalandoralsurgery
  • Anesthesiawhenclinicallynecessaryandrelatedtocoveredsurgery
  • Majorrestorativeservicesincludingcrowns,inlays,andonlays
  • Dentalimplants
  • Prosthodontics:Fullandpartialdentures,bridges
  • Fixedbridgeanddenturerepairs
  • Recementingofinlays,crowns,and/orbridges

PRE-TREATMENTESTIMATEOFBENEFITS:

Asaservicetoprotectmembers,whenchargesfromadentistforaproposedcourseoftreatmentareexpectedtobeover$250,apre-treatmentestimateofbenefitsisstronglyrecommendedbeforeanyservicesareperformed.

ENHANCEDPLANWITHORTHODONTIAOPTION

SAMEBENEFITSASTHEENHANCEDPLAN,PLUSORTHODONITIACOVERAGE

Eligibility/Participation:Atleast20%ofeligibleemployeeswithaminimumof5employeesLifetimeDeductible:$100perperson(allservicesexceptOrthodontia)

PriorCoverageCredit:Yes

MaximumContractYearBenefit:$1,000or$1,500

ORTHODONTIA:

-Nodeductible

-$1,000or$1,500LifetimeMaximum(mustbeconsistentwithmaximumcontractyearbenefitabove)

-Childrenunderage19only

DIAGNOSITCPREVENTIVESERVICES:100%Coverage

NoWaitingPeriod
  • Routineexams(twiceperbenefitperiod)
  • Cleanings:prophylaxis,includingscalingandpolishingabovethegumline(twiceperbenefitperiod)
  • Pulp-testing:evaluationoftoothnerve(limitedto1chargepervisit)
  • BitewingX-rays(onceperbenefitperiod)
  • Topicalfluorideapplicationforchildrenunderage19(onceperbenefitperiod)
  • Emergencytreatmentforpain
  • Sealantsforchildrenages6-15(onereapplicationpertoothevery5years)

BASICSERVICES:80%Coverage

NoWaitingPeriod
  • RoutineFillings
  • Simpleextractions
  • Endodonticsincludingrootcanal:Treatmentofthenervechamberandcanals
  • Periodontics:Treatmentofthediseaseofthegumsandbonesurroundingteeth
  • PeriapicalX-rayoftherootsofteeth
  • FullmouthX-ray(oneevery36monthsunlesstakenforcovereddiagnosis)

MAJORSERVICES:50%Coverage

12MonthWaitingPeriod
  • SpaceMaintainersforchildrenthroughage15
  • Surgicalteethremovalandoralsurgery
  • Anesthesiawhenclinicallynecessaryandrelatedtocoveredsurgery
  • Majorrestorativeservicesincludingcrowns,inlays,andonlays
  • Dentalimplants

PRE-TREATMENTESTIMATEOFBENEFITS:

Asaservicetoprotectmembers,whenchargesfromadentistforaproposedcourseoftreatmentareexpectedtobeover$250,apre-treatmentestimateofbenefitsisstronglyrecommendedbeforeanyservicesareperformed.

MONTHLYRATES

RatingTierOptions:

Employee

EmployeeSpouse

EmployeeChildren

Family

TheDentalBlueSelectrateslistedbelowareeffectivefromJanuary1,2017throughDecember31,2017andareguaranteedfor12monthsfromeffectivedate.

PlanOptions / Employee / EmployeeSpouse / EmployeeChildren / Family
Standard Plan
$1,000Max / $22.81 / $45.62 / $54.73 / $82.56
Complete Plan
$1,000Max / $31.34 / $62.71 / $75.20 / $113.48
Complete Plan
$1,500Max / $33.79 / $67.58 / $81.05 / $122.31
Complete PlanwithOrthodontia
$1,000Max / $31.65 / $63.31 / $75.92 / $114.57
Complete PlanwithOrthodontia
$1,500Max / $34.20 / $68.40 / $82.04 / $123.79
EnhancedPlan
$1,000Max / $37.76 / $75.53 / $90.60 / $136.68
EnhancedPlan
$1,500Max / $40.71 / $81.41 / $97.65 / $147.31
EnhancedPlanwithOrthodontia
$1,000Max / $38.15 / $76.28 / $91.51 / $138.05
Enhanced PlanwithOrthodontia
$1,500Max / $41.23 / $82.42 / $98.85 / $149.20

Thisproposalisnotacontract.Itisaproposaltoenteranagreementundercertaintermsandconditions,whichwillnotbebindinguntilreducedtowritingandexecutedbybothparties.

ADDITIONALINFORMATION

ELIGIBILITY:

Aneligibleemployeeisanactivefull-timeemployeeofthegroupwhoworks,year-round,aminimumof30hoursperweek,hasannualreportingofFICAwithholdingsbymeansofaW2andislistedonthegroup’swageandtaxstatement.Soleproprietorsandpartnersdevotingaminimumof30hoursperweektothebusinessareconsideredfull-timeemployees.Employeeswhoareissued1099formsforannualtaxfilingsarenotconsideredfull-timeemployeesandarethusineligible.

DEPENDENTS:

Dependentsinclude:

  • Spouse
  • Eligibledependentchildrenuptoage26,includingnaturalchildren,legallyadoptedchildren,mentallyretardedand/orphysicallydisabledchildreniftheconditionexistedandcoveragewasineffectuponattainmentofthelimitingage.
  • Domesticpartners,bothsamesexandoppositesex,forgroupswithover50members,ifelected.

IMPORTANTINFORMATION:

Thisproposalisnotacontractofinsurance.Itcontainsabriefdescriptionofbenefits.Finalinterpretation anda completelisting ofbenefitsandwhatisnot covered arefoundin and governedbythegroupcontractandthebenefitbooklet. YoumaypreviewthebenefitbookletbyrequestingacopyofthebenefitbookletfromDentalBlueSelectCustomerServiceat1-888-471-2738

BENEFITPERIOD:

Theperiodoftime,usually12monthsasstatedinthegroupcontract,duringwhichchargesforcoveredservicesprovidedtoamembermustbeincurredinordertobeeligibleforpaymentbyBlueCrossandBlueShieldofNorthCarolina.Achargeshallbeconsideredincurredonthedatetheserviceorsupplywasprovidedtoamember.

WAITINGPERIOD:

Waitingperiodsmayapplytosomeservices.Awaitingperiodistheamountoftimethatamembermustbeenrolledinthisdentalbenefitplanpriortoreceivingspecificservices.WaitingperiodsmaybewaivedonCompleteandEnhancedPlansonly,ifmembersmeetPriorCoverageCredit(Takeover)requirements.Waitingperiodswillnotbewaivedifmorethan63dayshavepassedbetweentheterminationofthepriorcoverageandtheeffectivedateofthecurrentcoverage.

PriorCoverageCredit(Takeover):

PriorcoveragecreditisavailableonCompleteandEnhancedplansonly.Toqualifyforpriorcoveragecredit,memberswhocandemonstrateproofofpriordentalcoveragemayhavetheirwaitingperiodswaivedorreduced.MembersmustsubmitproofofpriorcoveragebyprovidingabillorCertificateofCreditableCoveragelistingcoveredpersons’name,effectiveandtermdatesofcoveragefrompriorcarrier.

EXCLUSIONS:WHATISNOTCOVERED

Thefollowingaresummariesofsomeofthecoveragerestrictions.Afullexplanationandlistingofrestrictionswillbefoundinthebenefitbooklet.Yourdentalbenefitplandoesnotcoverservices,supplies,drugsorchargesthatare:

  • Notmedicallynecessary
  • Hospitalizationforanydentalprocedure
  • Dentalproceduressolelyforcosmeticoraestheticreasons
  • Dentalproceduresnotdirectlyassociatedwithdentaldisease
  • Proceduresnotperformedinadentalsetting
  • Proceduresthatareconsideredtobeexperimental
  • Drugsormedicationsobtainablewithorwithoutaprescription,unlesstheyaredispensedandutilizedinthedentalofficeduringthepatientvisit
  • Servicesrelatedtotemporomandibularjoint(TMJ)
  • Expensesfordentalproceduresbegunpriortothemember’seligibilitywithBlueCrossandBlueShieldofNorthCarolina
  • Clinicalsituationsthatcanbeeffectivelytreatedbyamorecosteffective,clinicallyacceptablealternativeprocedurewillbeassignedabenefitbasedonthelesscostlyprocedure
  • Dentalimplants,oralorthoticdevices,palatalexpandersandorthodonticsexceptasspecificallycoveredbyyourdentalbenefitplan

CONTACTS /RESOURCES

Formoreinformation,pleasecontactyourProducerorBCBSNCAccountManager,orGroupSalesat1-888-258-3496.

®Registeredmarkofthe BlueCrossandBlue Shield Association

SM Servicemarkof theBlueCrossandBlue Shield Association

Blue Crossand Blue Shield ofNorthCarolina isan independentlicensee ofthe Blue Crossand Blue Shield Association.

Version 11/2016