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© 2009 Blue Cross of Idaho. An Independent Licensee of the Blue Cross and Blue Shield Association.
Blue Cross of Idaho District Offices
Boise(Street Address)
3000 East Pine AvenueMeridian, ID 83642-5995
(Mailing Address)P.O. Box 7408, Boise, ID 83707
(208) 387-6683(800) 365-2345
(Dental Customer Service)(208) 363-8755(800) 289-7929
Coeur d’Alene2100 Northwest Boulevard, Suite 120
Coeur d’Alene, ID 83814(208) 666-1495
Idaho Falls2116 East 25th StreetIdaho Falls, ID 83404(Mailing Address)
P.O. Box 2287, Idaho Falls, ID 83403(208) 522-8813
Lewiston1010 17th Street
(Mailing Address)P.O. Box 1468, Lewiston, ID 83501
(208) 746-0531
Pocatello275 South 5th Avenue, Suite 150
Pocatello, ID 83201(Mailing Address)
P.O. Box 2578, Pocatello, ID 83206(208) 232-6206
Twin Falls1431 North Fillmore Street, Suite 200
Twin Falls, ID 83301(Mailing Address)
P.O. Box 5025, Twin Falls, ID 83303-5025(208) 733-7258
www.bcidaho.com
Maximum allowance for contracting orin-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 benefi ts are available for services that are:
■ Not specifi cally 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.
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.
one one
Dental Blue® PPO
TO
Form No. 15-009 (03-08)
You think about fi ndingaffordable dental coverage.
■
We think our flexible andaffordable dental benefits
will make you smile.
An Individual Stand-alone Dental Program
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 Benefits
Major 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.
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.
(continued)
Please note that there is a six-month waiting period for basic care benefits and a 12-month waiting period for major care benefits.
Dental Blue® PPO – An Individual Dental Program
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 $20 per visit copayment 70% of the maximum allowance3
Basic Care Services1 80% of the maximum allowance3 60% of the maximum allowance3
Major Care Services2 50% of the maximum allowance3 40% of the maximum allowance3
1 Basic care services have a six-month waiting period2 Major care services have a 12-month waiting period3 Deductible applies to out-of-network preventive services and in- or out-of-network basic and major services
dent
al b
lue®
ppo
in
divi
dual
enr
ollm
ent
appl
icat
ion
App
lican
t In
form
atio
n (A
pplic
ants
age
65
and
olde
r ar
e no
t el
igib
le)
Your
Nam
e (fi
rst,
initi
al, l
ast)
Dat
e of
Birt
h (m
m/d
d/yy
)So
cial
Sec
urity
Num
ber
Bus
ines
s Ph
one
Hom
e Ph
one
Mai
ling
Add
ress
(stre
et o
r rou
te)
City
, Sta
te, Z
ip C
ode
Cou
nty
Bill
ing
Add
ress
(if d
iffer
ent f
rom
mai
ling
addr
ess)
City
, Sta
te, Z
ip C
ode
Cou
nty
Nam
e of
Em
ploy
erYo
ur O
ccup
atio
nId
aho
resi
dent
? q
Yes
q N
oIf
yes,
how
long
? _
____
___
Mar
ital S
tatu
s: ❒
Sin
gle
❒
Mar
ried
❒ D
ivor
ced
❒ W
idow
ed❒
Mal
e ❒
Fem
ale
Pro
gram
Inf
orm
atio
n
❒ D
enta
l Blu
e 10
00 ($
1,00
0 B
enef
it Pe
riod
Max
)
(s
ix-m
onth
wai
ting
perio
d fo
r bas
ic ca
re/1
2-m
onth
wai
ting
perio
d fo
r maj
or c
are)
❒ D
enta
l Blu
e 15
00 ($
1,50
0 B
enef
it Pe
riod
Max
)
Requ
este
d Ef
fect
ive D
ate
/
/
(Ear
liest
effe
ctive
dat
e wi
ll be
the
1st o
f the
mon
th fo
llowi
ng a
ppro
val.)
Oth
er C
over
age
Info
rmat
ion
Is a
ny p
erso
n lis
ted
on th
is a
pplic
atio
n no
w c
over
ed o
r has
he
or s
he b
een
cove
red
by a
ny k
ind
of d
enta
l ins
uran
ce ?
❒
YES
❒
NO
If
YES:
Nam
e(s)
of o
ther
den
tal i
nsur
ance
car
rier(
s) _
____
____
____
____
____
____
____
____
____
____
____
____
____
_
Polic
y nu
mbe
r(s)
___
____
____
____
____
____
___
City
/Sta
te _
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
__
____
____
____
____
____
____
Pers
on(s
) cov
ered
und
er th
e po
licy
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
__
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
Cha
nge
Req
uest
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
ddit
iona
l F
amily
Mem
ber
Info
rmat
ion
(Fam
ily m
embe
rs a
ge 6
5 an
d ol
der
are
not
elig
ible
)
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 d
epen
-de
nt u
pon
you;
or w
ho is
med
ical
ly c
ertif
ied
as d
isab
led
and
depe
nden
t upo
n yo
u fo
r sup
port
(cop
y of
cer
tific
atio
n re
quire
d).
Fam
ily M
embe
r’s N
ame
(firs
t, in
itial
, las
t)R
elat
ions
hip
to A
pplic
ant
(spo
use,
chi
ld, s
tepc
hild
, etc
.)D
ate
of B
irth
(mm
/dd/
yy)
Age
❒
Mal
e ❒
Fem
ale
Fam
ily M
embe
r’s N
ame
(firs
t, in
itial
, las
t)D
ate
of B
irth
(mm
/dd/
yy)
Age
❒
Mal
e ❒
Fem
ale
Fam
ily M
embe
r’s N
ame
(firs
t, in
itial
, las
t)D
ate
of B
irth
(mm
/dd/
yy)
Age
❒
Mal
e ❒
Fem
ale
Fam
ily M
embe
r’s N
ame
(firs
t, in
itial
, las
t)D
ate
of B
irth
(mm
/dd/
yy)
Age
❒
Mal
e ❒
Fem
ale
Fam
ily M
embe
r’s N
ame
(firs
t, in
itial
, las
t)D
ate
of B
irth
(mm
/dd/
yy)
Age
❒
Mal
e ❒
Fem
ale
Par
enta
l or
Gua
rdia
n C
onse
nt t
o A
pplic
atio
n (O
nly
if ap
plic
ant
is u
nder
age
18)
I rep
rese
nt th
at th
e pe
rson
list
ed a
s th
e ap
plic
ant o
n th
is a
pplic
atio
n is
und
er 1
8 ye
ars
of a
ge a
nd is
app
lyin
g fo
r Blu
e C
ross
of I
daho
hea
lth c
over
age
with
my
full
know
ledg
e an
d co
nsen
t. I
acce
pt fu
ll re
spon
sibi
lity
for t
he p
aym
ent o
f pre
miu
ms
and
the
info
rmat
ion
prov
ided
on
this
app
licat
ion.
Sign
atur
ePr
int N
ame
Dat
e
Inde
pend
ent P
rodu
cer’s
Nam
e __
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
__ B
CI _
____
____
____
____
____
Off
ice
Use
Onl
y
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
Stre
et A
ddre
ss: 3
000
E. P
ine
Ave
., M
erid
ian,
ID 8
3642
-599
5 • M
ailin
g Ad
dres
s: P
.O. B
ox 7
408,
Boi
se, I
D 8
3707
-140
8 •
(208
) 345
-455
0
Form
No.
15-
008
(05-
06)
/
/
/
/
/
/
/
/
/
/
/
/
/
/
An
In
dep
end
ent
Lice
nse
e of
th
e B
lue
Cro
ss a
nd
Blu
e S
hie
ld A
ssoc
iatio
n
Paym
ent Options (1st m
onths premium
required with application – N
o $2 service fee required on first month)
❐ A
utomatic m
onthly bank withdraw
al (complete authorization below)
❐ M
onthly – direct coupon (payment m
ust include $2 monthly service fee)
Authorization A
greement for B
ank Withdraw
al
I or we, m
eaning my spouse if applicable, authorize and re-
quest 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 assum
es full responsibility for correctly inform
ing the bank of the specific am
ount of each deduction. I or we m
ay terminate this agreem
ent at any tim
e by notifying BC
I or the bank in writing. Term
ination will
take effect after BC
I or the bank has received the written notice
and had a reasonable amount of tim
e to act on it.
Bank N
ame _________________________________________________________________
Bank A
ddress (city, state) _______________________________________________________
Custom
er Bank A
ccount No.________________________
C
ompany I.D
. No. 0000500005
Signed ________________________________________________ D
ate _________________
Signed ________________________________________________ D
ate _________________
Transit R
outing No.
Account N
umber
Please attach voided check for automatic bank w
ithdrawal.
Statement of U
nderstanding
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 completely
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 facsimile 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 m
aterial 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
payment
submitted
with
this application
will be refunded. U
pon the refund of the payment, B
lue Cross of Idaho w
ill have no further obligations to m
e or any family m
ember listed on this application.
• If this application is approved, coverage for myself and any eligible fam
ily mem
bers nam
ed on this application will begin on the date assigned by B
lue Cross of Idaho.
• If this application is approved, I understand a copy of the application will be attached
to my policy. I approve the inclusion of any needed alterations to the application as long
as I have been consulted by a duly authorized employee of B
lue Cross of Idaho or a
licensed and duly appointed Independent Producer representing me, and I have had an
opportunity to review the application that w
ill 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.bcidaho.com
.• I affirm
that I have reviewed all answ
ers given on this application and, if an independent producer or other person has filled out the answ
ers for me, I verify
that the answers are true and com
plete. I understand that this application is a legal docum
ent and will becom
e part of the contract between Blue Cross of Idaho
and the enrollee.
X _____________________________________________
________________
Applicant’s Signature
Date (Parent or G
uardian's signature if applicant is under age 18)
X _____________________________________________
________________
Spouse’s Signature (if listed on application)
Date
For Independent P
roducers Only
Independent Producer Checklist
❒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 paperwork 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?❒
Are all paym
ents attached to the front of the application?❒
If one check is written for split applications, is a breakdow
n of amounts that apply to each application included?
Independent Producer Certification
1. W
ho actually completed this application? ❒
Applicant ❒
Independent Producer ❒ O
ther
If Independent Producer or O
ther, please explain ______________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________
2. W
ere you present at the time the application w
as filled out? ❒ YES ❒
NO
If NO, please explain ________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________
3. W
as money collected from
the applicant? ❒ YES ❒
NO Amount $ __________________________________________________________________________________
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 m
aterial 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 Producer’s Printed Nam
e Independent Producer’s Signature
Date Blue Cross of Idaho No.
Type of Com
pany Appointment ❐
Personal ❐Agency (Nam
e) _________________________________________________________________________________
....
Transit AB
A❐
Checking ❐
Savings