BlueDental Choice & Copayment Complete Community Rated Plan Matrix for Groups 4-50 Community Rated Matrix For Agent Use Only
Plans Rollover rates are shown on page 9. BlueDental Choice Copayment PPO Community Rated Plans Rates Effective: 7/01/2010 Plan 109 Plans (Employer Contribution-minimum 50%) Plan 109 Plan 109 Plan 114 Plan 114 Plan 114 Set Copayment Schedule For In-Network Services Yes Yes Yes Yes Yes Yes Yes Yes Yes Out-of-Network Coinsurance Percentage 80/60/40 80/60/40 80/60/40 80/60/40 80/60/40 80/60/40 100/80/50 100/80/50 100/80/50 Employer Contribution (Minimum required for Dental) 50% 50% 50% 50% 50% 50% 50% 50% 50% Plan 131 Plan 131 Plan 131 Minimum Participation % or # of lives, whichever is greater Cleaning Copayment $10 $10 $10 $0 $0 $0 $10 $10 $10 In-Network Deductible Individual/ $50/$150 $50/$150 $50/$150 None None None None None None Out-of-Network Deductible Individual/ $50/$150 $50/$150 $50/$150 $50/$150 $50/$150 $50/$150 $50/$150 $50/$150 $50/$150 Plan Year Maximum $1,000 $1,000 $1,000 $1,000 $1,000 $1,000 $1,000 $1,000 $1,000 Orthodontics* N/A Child Only** Child Only** N/A Child Only** Child Only** N/A Child Only** Child Only** Ortho Coinsurance Percentage N/A 50% 50% N/A 50% 50% N/A 50% 50% Ortho Lifetime Maximum N/A $750 $1,000 N/A $750 $1,000 N/A $750 $1,000 $11.93 $34.60 $12.01 $38.30 $39.06 $13.53 $39.20 $13.61 $42.90 $13.62 $43.66 $14.13 $40.96 $14.21 $44.66 $14.23 $45.42 $11.93 $24.58 $40.43 $12.01 $25.37 $45.90 $25.55 $47.04 $13.53 $27.85 $45.81 $13.61 $28.64 $51.29 $13.62 $28.81 $52.42 $14.13 $29.09 $47.85 $14.21 $29.89 $53.33 $14.23 $30.06 $54.46 $11.93 $25.98 $25.34 $40.75 $12.01 $26.14 $30.37 $45.86 $26.17 $31.41 $46.92 $13.53 $29.43 $28.71 $46.18 $13.61 $29.58 $33.74 $51.29 $13.62 $29.62 $34.77 $52.34 $14.13 $30.76 $30.00 $48.42 $14.21 $30.91 $35.03 $53.52 $14.23 $30.95 $36.06 $54.58 * Orthodontic benefits are available for groups with a minimum of 5 child/family units ** Children to age 19 Out-of-Network coinsurance is paid based upon the In-Network dentist fee schedule Restricted Industries require a minimum group size of 10 and underwriting approval. 4-9 life groups in Restricted Industries are only eligible for BlueDental Care (prepaid) plans, when located in counties where this product is marketed. 2 22210-0710R
Plans Rollover rates are shown on page 9. BlueDental Choice Copayment PPO Community Rated Plans Rates Effective: 7/01/2010 Set Copayment Schedule For In-Network Services Out-of-Network Coinsurance Percentage Employer Contribution (Minimum required for Dental) Minimum Participation % or # of lives, whichever is greater Plan 209 Plan 209 Plan 209 Plan 213 Group Plans (No Employer Contribution Required) Plan 213 Plan 213 Plan 219 Plan 219 Plan 229 Plan 229 Plan 229 Plan 231 Plan 231 Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Plan 231 80/60/40 80/60/40 80/60/40 80/60/40 80/60/40 80/60/40 70/50/35 70/50/35 100/80/50 100/80/50 100/80/50 100/80/50 100/80/50 100/80/50 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% Cleaning Copayment $10 $10 $10 $10 $10 $10 $10 $10 $10 $10 $10 $10 $10 $10 In-Network Deductible Individual/ Out-of-Network Deductible Individual/ $50/$150 $50/$150 $50/$150 None None None $50/$150 $50/$150 $50/$150 $50/$150 $50/$150 None None None $50/$150 $50/$150 $50/$150 $50/$150 $50/$150 $50/$150 $50/$150 $50/$150 $50/$150 $50/$150 $50/$150 $50/$150 $50/$150 $50/$150 Plan Year Maximum $1,000 $1,000 $1,000 $1,000 $1,000 $1,000 $750* $750* $1,000 $1,000 $1,000 $1,000 $1,000 $1,000 Orthodontics* N/A Child Only** Child Only** N/A Child Only** Child Only** N/A Child Only** N/A Child Only** Child Only** N/A Child Only** Child Only** Ortho Coinsurance Percentage N/A 50% 50% N/A 50% 50% N/A 50% N/A 50% 50% N/A 50% 50% Ortho Lifetime Maximum N/A $750 $1,000 N/A $750 $1,000 N/A $750 N/A $750 $1,000 N/A $750 $1,000 $14.25 $41.33 $14.35 $45.74 $14.37 $46.66 $45.23 $15.70 $49.64 $15.72 $50.55 $12.81 $37.15 $12.91 $41.56 $15.53 $45.02 $15.63 $49.43 $15.65 $50.34 $16.88 $48.92 $53.33 $17.00 $54.25 $14.25 $29.35 $48.27 $14.35 $30.30 $54.82 $14.37 $30.50 $56.17 $32.12 $52.83 $15.70 $33.07 $59.38 $15.72 $33.27 $60.73 $12.81 $26.38 $43.40 $12.91 $27.34 $49.94 $15.53 $31.97 $52.60 $15.63 $32.93 $58.99 $15.65 $33.13 $60.50 $16.88 $34.74 $57.15 $35.70 $63.69 $17.00 $35.90 $65.05 $14.25 $31.03 $30.25 $48.67 $14.35 $31.22 $36.26 $54.76 $14.37 $31.26 $37.49 $56.03 $33.96 $33.12 $53.27 $15.70 $34.16 $39.12 $59.37 $15.72 $34.19 $40.36 $60.64 $12.81 $27.89 $27.20 $43.75 $12.91 $28.08 $33.21 $49.85 $15.53 $33.80 $32.96 $53.03 $15.63 $33.99 $38.97 $59.12 $15.65 $34.03 $40.20 $60.39 $16.88 $36.74 $35.82 $57.63 $36.93 $41.83 $63.72 $17.00 $36.97 $43.06 $64.99 * Orthodontic benefits are available for groups with a minimum of 5 child/family units ** Children to age 19 Out-of-Network coinsurance is paid based upon the In-Network dentist fee schedule Restricted Industries require a minimum group size of 10 and underwriting approval. 4-9 life groups in Restricted Industries are only eligible for BlueDental Care (prepaid) plans, when located in counties where this product is marketed. 3 22210-0710R
Plans Rollover and Ortho rates are shown on page 9. BlueDental Choice PPO Community Rated Plans Rates Effective 10/15/2011 Plan 301 Plan 302 Plan 303 Plan 304 Plans (Employer Contribution - minimum 50%) Plan 305 Plan 306 Plan 307 In-Network Coinsurance Percentage 100/80/50 100/80/50 100/80/50 100/80/50 100/80/50 100/80/50 100/80/50 100/80/50 100/80/50 80/60/40 100/80/50 100/80/50 100/80/50 100/80/50 100/60/50 80/80/50 Out-of-Network Coinsurance Percentage 80/60/40 80/60/40 80/60/40 80/60/40 100/80/50 100/80/50 100/80/50 100/80/50 70/50/30 70/50/30 100/50/25 90/60/40 80/70/40 80/50/40 80/40/30 60/60/40 Employer Contribution (Minimum required for Dental) Minimum Participation % or # of lives, whichever is greater Plan 308 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% Deductible Individual/ $50/$150 $50/$150 $50/$150 $75/$225 $50/$150 $50/$150 $50/$150 $75/$225 $75/$225 $75/$225 $50/$150 $50/$150 $50/$150 $50/$150 $50/$150 $50/$150 Plan Year Maximum $1,000 $1,250 $1,500 $1,000 $1,000 $1,250 $1,500 $1,000 $1,000 $750 $1,000 $1,000 $1,000 $1,000 $1,000 $1,000 Endo/Perio Covered as Basic Basic Basic Basic Basic Basic Basic Basic Basic Basic Basic Basic Basic Basic Basic Basic Area 1 - Alachua, Bay, Citrus, Clay, Columbia, Duval, Escambia, Flagler, Gulf, Hernando, Highlands, Hillsborough, Jackson, Lake, Leon, Marion, Nassau, Okaloosa, Orange, Osceola, Pasco, Pinellas, Polk, St. Johns, Santa Rosa, Seminole, Volusia, Walton $17.56 $47.19 $17.56 $33.96 $55.35 $17.56 $36.08 $37.56 $56.06 $18.43 $49.51 $18.43 $35.63 $58.08 $18.43 $37.85 $39.40 $58.82 $51.92 $37.67 $60.70 $40.14 $40.95 $61.57 $16.79 $45.17 $16.79 $32.50 $52.96 $16.79 $34.54 $35.91 $53.65 $19.23 $51.70 $19.23 $37.17 $60.65 $19.23 $39.48 $41.17 $61.43 $20.17 $54.23 $20.17 $39.02 $63.64 $20.17 $41.43 $43.20 $64.45 $21.39 $56.95 $21.39 $41.29 $66.59 $21.39 $43.99 $44.92 $67.52 $49.45 $35.57 $58.02 $37.78 $39.38 $58.77 Plan 309 $15.80 $42.55 $15.80 $30.57 $49.94 $15.80 $32.48 $33.90 $50.58 Plan 310 $10.65 $28.91 $10.65 $20.63 $34.00 $10.65 $21.86 $23.16 $34.40 Plan 311 $46.10 $32.91 $54.24 $34.86 $37.01 $54.89 Plan 312 $17.80 $47.89 $17.80 $34.40 $56.20 $17.80 $36.54 $38.16 $56.92 Plan 313 $17.95 $48.27 $17.95 $34.72 $56.63 $17.95 $36.86 $38.45 $57.35 Plan 314 $17.18 $46.13 $17.18 $33.23 $54.09 $17.18 $35.31 $36.68 $54.80 Plan 315 $14.40 $38.65 $14.40 $27.88 $45.30 $14.40 $29.64 $30.67 $45.91 Plan 316 $15.93 $42.12 $15.93 $30.69 $49.16 $15.93 $32.74 $33.08 $49.89 Area 2 - Baker, Bradford, Calhoun, DeSoto, Dixie, Franklin, Gadsden, Gilchrist, Glades, Hamilton, Hardee, Hendry, Holmes, Jefferson, Lafayette, Levy, Liberty, Madison, Okeechobee, Putnam, Sumter, Suwannee, Taylor, Union, Wakulla, Washington $17.22 $46.26 $17.22 $33.29 $54.26 $17.22 $35.37 $36.82 $54.96 $18.07 $48.54 $18.07 $34.93 $56.94 $18.07 $37.11 $38.63 $57.67 $50.90 $36.93 $59.51 $39.35 $40.15 $60.36 $16.46 $44.28 $16.46 $31.86 $51.92 $16.46 $33.86 $35.21 $52.60 $18.85 $50.69 $18.85 $36.44 $59.46 $18.85 $38.71 $40.36 $60.23 $19.77 $53.17 $19.77 $38.25 $62.39 $19.77 $40.62 $42.35 $63.19 $55.83 $40.48 $65.28 $43.13 $44.04 $66.20 $18.02 $48.48 $18.02 $34.87 $56.88 $18.02 $37.04 $38.61 $57.62 $15.49 $41.72 $15.49 $29.97 $48.96 $15.49 $31.84 $33.24 $49.59 $10.44 $28.34 $10.44 $20.23 $33.33 $10.44 $21.43 $22.71 $33.73 $16.65 $45.20 $16.65 $32.26 $53.18 $16.65 $34.18 $36.28 $53.81 $17.45 $46.95 $17.45 $33.73 $55.10 $17.45 $35.82 $37.41 $55.80 $17.60 $47.32 $17.60 $34.04 $55.52 $17.60 $36.14 $37.70 $56.23 $16.84 $45.23 $16.84 $32.58 $53.03 $16.84 $34.62 $35.96 $53.73 $14.12 $37.89 $14.12 $27.33 $44.41 $14.12 $29.06 $30.07 $45.01 $15.62 $41.29 $15.62 $30.09 $48.20 $15.62 $32.10 $32.43 $48.91 Area 3 - Brevard, Charlotte, Indian River, Lee, Manatee, Martin, St. Lucie, Sarasota $19.84 $53.31 $19.84 $38.36 $62.53 $20.82 $55.94 $20.82 $40.25 $65.61 $22.05 $58.66 $22.05 $42.55 $68.58 $18.97 $51.02 $18.97 $36.72 $59.83 $21.72 $58.41 $21.72 $41.99 $68.52 $22.79 $61.27 $22.79 $44.07 $71.89 $24.17 $64.33 $24.17 $46.65 $75.22 $20.76 $55.87 $20.76 $40.18 $65.55 $17.85 $48.08 $17.85 $34.54 $56.42 $32.66 $23.31 $38.41 $19.19 $52.09 $19.19 $37.18 $61.28 $20.11 $54.10 $20.11 $38.87 $63.49 $20.28 $54.53 $20.28 $39.22 $63.98 $52.12 $37.54 $61.11 $16.27 $43.67 $16.27 $31.49 $51.18 $18.00 $47.59 $18.00 $34.67 $55.54 $19.84 $40.76 $42.43 $63.34 20.82 $42.77 $44.52 $66.46 $22.05 $45.34 $46.27 $69.56 $18.97 $39.02 $40.58 $60.62 $21.72 $44.61 $46.51 $69.41 $22.79 $46.81 $48.81 $72.82 $24.17 $49.71 $50.75 $76.29 $20.76 $42.69 $44.49 $66.40 $17.85 $36.69 $38.30 $57.15 $24.69 $26.17 $38.87 $19.19 $39.39 $41.81 $62.01 $20.11 $41.28 $43.11 $64.30 $20.28 $41.64 $43.44 $64.80 $39.89 $41.44 $61.92 $16.27 $33.48 $34.65 $51.87 $18.00 $37.00 $37.37 $56.37 Area 4 - Broward, Collier, Miami-Dade, Monroe, Palm Beach $22.49 $60.33 $22.49 $43.46 $70.73 $22.49 $46.20 $47.97 $71.67 $23.60 $63.30 $23.60 $45.60 $74.21 $23.60 $48.47 $50.33 $75.19 $24.99 $66.33 $24.99 $48.17 $77.53 $24.99 $51.34 $52.29 $78.66 $21.59 $57.92 $21.59 $41.72 $67.90 $21.59 $44.36 $46.03 $68.79 $24.63 $66.09 $24.63 $47.59 $77.51 $24.63 $50.57 $52.59 $78.52 Out-of-Network coinsurance is paid based upon the In-Network dentist fee schedule Refer to Underwriting guidelines attached. Restricted Industries require a minimum group size of 10 and underwriting approval. 4-9 life groups in Restricted Industries are only eligible for BlueDental Care (prepaid) plans, when located in counties where this product is mar- $25.84 $69.35 $25.84 $49.93 $81.32 $25.84 $53.05 $55.18 $82.39 $27.39 $72.76 $27.39 $52.82 $85.04 $27.39 $56.28 $57.36 $86.25 4 $23.63 $63.45 $23.63 $45.67 $74.39 $23.63 $48.54 $50.45 $75.38 $20.30 $54.59 $20.30 $39.27 $64.03 $20.30 $41.72 $43.46 $64.86 $13.68 $37.08 $13.68 $26.52 $43.59 $13.68 $28.11 $29.70 $44.11 $21.76 $58.96 $21.76 $42.13 $69.33 $21.76 $44.65 $47.27 $70.17 $22.78 $61.22 $22.78 $44.03 $71.81 $22.78 $46.77 $48.75 $72.74 $23.00 $61.72 $23.00 $44.43 $72.37 $23.00 $47.20 $49.11 $73.31 $22.01 $58.96 $22.01 $42.51 $69.12 $22.01 $45.19 $46.84 $70.03 $18.42 $49.36 $18.42 $35.62 $57.83 $18.42 $37.89 $39.14 $58.61 $20.42 $53.84 $20.42 $39.27 $62.82 $20.42 $41.92 $42.26 $63.76
Plans Rollover and Ortho rates are shown on page 9. BlueDental Choice PPO Community Rated Plans Rates Effective 10/15/2011 Plan 351 Plan 352 Plan 353 Plans (Employer Contribution-minimum 50%) Plan 354 Plan 355 Plan 356 Plan 357 In-Network Coinsurance Percentage 100/80/50 100/80/50 100/80/50 100/80/50 100/80/50 100/80/50 100/80/50 100/80/50 100/80/50 80/60/40 100/80/50 100/80/50 100/80/50 100/80/50 100/60/50 80/80/50 Out-of-Network Coinsurance Percentage 80/60/40 80/60/40 80/60/40 80/60/40 100/80/50 100/80/50 100/80/50 100/80/50 70/50/30 70/50/30 100/50/25 90/60/40 80/70/40 80/50/40 80/40/30 60/60/40 Employer Contribution (Minimum required for Dental) 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% Minimum Participation % or # of lives, whichever is greater Deductible Individual/ $50/$150 $50/$150 $50/$150 $75/$225 $50/$150 $50/$150 $50/$150 $75/$225 $75/$225 $75/$225 $50/$150 $50/$150 $50/$150 $50/$150 $50/$150 $50/$150 Plan Year Maximum $1,000 $1,250 $1,500 $1,000 $1,000 $1,250 $1,500 $1,000 $1,000 $750 $1,000 $1,000 $1,000 $1,000 $1,000 $1,000 Endo/Perio Covered as Major Major Major Major Major Major Major Major Major Major Major Major Major Major Major Major Plan 358 Plan 359 Plan 360 Plan 361 Plan 362 Plan 363 Plan 364 Plan 365 Plan 366 Area 1 - Alachua, Bay, Citrus, Clay, Columbia, Duval, Escambia, Flagler, Gulf, Hernando, Highlands, Hillsborough, Jackson, Lake, Leon, Marion, Nassau, Okaloosa, Orange, Osceola, Pasco, Pinellas, Polk, St. Johns, Santa Rosa, Seminole, Volusia, Walton $16.36 $44.85 $16.36 $31.82 $52.88 $16.36 $33.66 $36.16 $53.47 $17.17 $47.05 $17.17 $33.39 $55.48 $17.17 $35.31 $37.94 $56.10 $49.85 $35.79 $58.52 $38.01 $39.72 $59.27 $42.83 $30.39 $50.52 $32.13 $34.54 $51.07 $17.88 $49.07 $17.88 $34.78 $57.87 $17.88 $36.76 $39.61 $58.51 $51.49 $36.50 $60.72 $38.58 $41.55 $61.38 $20.21 $54.62 $20.21 $39.19 $64.14 $20.21 $41.61 $43.55 $64.95 $17.03 $46.86 $17.03 $33.20 $55.27 $17.03 $35.10 $37.82 $55.88 $14.63 $40.30 $14.63 $28.53 $47.56 $14.63 $30.14 $32.58 $48.06 $9.78 $27.24 $9.78 $32.25 $9.78 $20.17 $22.20 $32.55 $15.77 $43.76 $15.77 $30.77 $51.75 $15.77 $32.44 $35.60 $52.26 $16.58 $45.54 $16.58 $32.27 $53.71 $16.58 $34.10 $36.76 $54.30 $45.71 $32.39 $53.93 $34.22 $36.92 $54.51 $16.10 $43.99 $16.10 $31.28 $51.85 $16.10 $33.11 $35.41 $52.45 $13.93 $37.73 $13.93 $27.03 $44.31 $13.93 $28.68 $30.12 $44.87 $39.80 $28.57 $46.71 $30.33 $31.70 $47.31 Area 2 - Baker, Bradford, Calhoun, DeSoto, Dixie, Franklin, Gadsden, Gilchrist, Glades, Hamilton, Hardee, Hendry, Holmes, Jefferson, Lafayette, Levy, Liberty, Madison, Okeechobee, Putnam, Sumter, Suwannee, Taylor, Union, Wakulla, Washington $16.04 $43.97 $16.04 $31.20 $51.84 $16.04 $33.00 $35.45 $52.42 $16.83 $46.13 $16.83 $32.74 $54.39 $16.83 $34.62 $37.20 $55.00 $18.10 $48.87 $18.10 $35.09 $57.37 $18.10 $37.26 $38.94 $58.11 $15.29 $41.99 $15.29 $29.79 $49.53 $15.29 $31.50 $33.86 $50.07 $17.53 $48.11 $17.53 $34.10 $56.74 $17.53 $36.04 $38.83 $57.36 $50.48 $35.78 $59.53 $37.82 $40.74 $60.18 $19.81 $53.55 $19.81 $38.42 $62.88 $19.81 $40.79 $42.70 $63.68 $16.70 $45.94 $16.70 $32.55 $54.19 $16.70 $34.41 $37.08 $54.78 $14.34 $39.51 $14.34 $27.97 $46.63 $14.34 $29.55 $31.94 $47.12 $9.59 $26.71 $9.59 $18.76 $31.62 $9.59 $19.77 $21.76 $31.91 $15.46 $42.90 $15.46 $30.17 $50.74 $15.46 $31.80 $34.90 $51.24 $16.25 $44.65 $16.25 $31.64 $52.66 $16.25 $33.43 $36.04 $53.24 $44.81 $31.75 $52.87 $33.55 $36.20 $53.44 $15.78 $43.13 $15.78 $30.67 $50.83 $15.78 $32.46 $34.72 $51.42 $13.66 $36.99 $13.66 $26.50 $43.44 $13.66 $28.12 $29.53 $43.99 $14.46 $39.02 $14.46 $28.01 $45.79 $14.46 $29.74 $31.08 $46.38 Area 3 - Brevard, Charlotte, Indian River, Lee, Manatee, Martin, St. Lucie, Sarasota $18.49 $50.67 $18.49 $35.95 $59.74 $19.40 $53.16 $19.40 $37.73 $62.68 $20.86 $56.32 $20.86 $40.43 $66.11 $48.39 $34.33 $57.07 $20.20 $55.44 $20.20 $39.30 $65.39 $21.18 $58.17 $21.18 $41.24 $68.60 $61.71 $44.28 $72.46 $19.24 $52.94 $19.24 $37.51 $62.45 $16.52 $45.53 $16.52 $32.23 $53.73 $11.05 $30.78 $11.05 $21.62 $36.44 $17.81 $49.44 $17.81 $34.77 $58.48 $18.73 $51.45 $18.73 $36.46 $60.68 $51.64 $36.59 $60.93 $18.18 $49.71 $18.18 $35.34 $58.57 $15.74 $42.62 $15.74 $30.54 $50.06 $44.96 $32.28 $52.77 $18.49 $38.02 $40.85 $60.40 $19.40 $39.90 $42.86 $63.38 $20.86 $42.94 $44.88 $66.97 $36.30 $39.02 $57.70 $20.20 $41.54 $44.75 $66.10 $21.18 $43.58 $46.95 $69.35 $47.01 $49.20 $73.38 $19.24 $39.66 $42.73 $63.13 $16.52 $34.05 $36.80 $54.30 $11.05 $22.78 $25.07 $36.77 $17.81 $36.65 $40.22 $59.05 $18.73 $38.53 $41.54 $61.35 $38.66 $41.72 $61.58 $18.18 $37.40 $40.01 $59.25 $15.74 $32.41 $34.03 $50.69 $34.28 $35.82 $53.44 Area 4 - Broward, Collier, Miami-Dade, Monroe, Palm Beach $20.89 $57.20 $20.89 $40.62 $67.43 $21.91 $60.02 $21.91 $42.61 $70.75 $23.56 $63.57 $23.56 $45.66 $74.63 $19.99 $54.82 $19.99 $38.90 $64.64 $62.59 $44.40 $73.81 $23.95 $65.67 $23.95 $46.58 $77.44 $25.80 $69.66 $25.80 $50.00 $81.79 $21.83 $59.96 $21.83 $42.51 $70.73 $51.57 $36.52 $60.86 $12.55 $34.88 $12.55 $24.50 $41.26 $20.14 $55.82 $20.14 $39.27 $66.03 $21.17 $58.08 $21.17 $41.19 $68.51 $58.30 $41.32 $68.77 $20.55 $56.12 $20.55 $39.92 $66.11 $17.77 $48.12 $17.77 $34.49 $56.52 $18.82 $50.75 $18.82 $36.45 $59.54 $20.89 $42.96 $46.11 $68.19 $21.91 $45.08 $48.39 $71.54 $23.56 $48.49 $50.65 $75.58 $19.99 $41.14 $44.20 $65.36 $46.93 $50.52 $74.62 $23.95 $49.25 $53.00 $78.30 $25.80 $53.09 $55.54 $82.83 $21.83 $44.95 $48.39 $71.51 $38.59 $41.67 $61.52 $12.55 $25.82 $28.39 $41.66 $20.14 $41.40 $45.41 $66.68 $21.17 $43.54 $46.90 $69.25 $43.68 $47.09 $69.52 $20.55 $42.25 $45.15 $66.88 $17.77 $36.61 $38.40 $57.23 $18.82 $38.73 $40.41 $60.32 Out-of-Network coinsurance is paid based upon the In-Network dentist fee schedule Refer to Underwriting guidelines attached. Restricted Industries require a minimum group size of 10 and underwriting approval. 4-9 life groups in Restricted Industries are only eligible for BlueDental Care (prepaid) plans, when located in counties where this product is marketed. 5
Plans Rollover and Ortho rates are shown on page 9. BlueDental Choice PPO Community Rated Plans Rates Effective 10/15/2011 Plan 401 Group Plans (No Employer Contribution Required) Plan 404 Plan 410 In-Network Coinsurance Percentage 100/80/50 100/80/50 80/60/40 100/80/50 100/80/50 100/80/50 100/80/50 100/60/50 80/80/50 100/80/50 100/80/0 100/50/25 Out-of-Network Coinsurance Percentage 80/60/40 80/60/40 70/50/30 100/50/25 90/60/40 80/70/40 80/50/40 80/40/30 60/60/40 70/50/30 100/80/0 80/50/25 Employer Contribution (Minimum required for Dental) 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% Minimum Participation % or # of lives, whichever is greater Deductible Individual/ $50/$150 $75/$225 $75/$225 $50/$150 $50/$150 $50/$150 $50/$150 $50/$150 $50/$150 $75/$225 $75/$225 $75/$225 Plan Year Maximum $1,000 $1,000 $750 $1,000 $1,000 $1,000 $1,000 $1,000 $1,000 $750 $750 $1,000 Endo/Perio Covered as Basic Basic Basic Basic Basic Basic Basic Basic Basic Basic Basic Basic Area 1 - Alachua, Bay, Citrus, Clay, Columbia, Duval, Escambia, Flagler, Gulf, Hernando, Highlands, Hillsborough, Jackson, Lake, Leon, Marion, Nassau, Okaloosa, Orange, Osceola, Pasco, Pinellas, Polk, St. Johns, Santa Rosa, Seminole, Volusia, Walton $56.37 $40.56 $66.11 $43.08 $44.85 $66.95 $20.05 $53.93 $20.05 $38.81 $63.25 $20.05 $41.24 $42.90 $64.08 $12.71 $34.52 $12.71 $24.65 $40.60 $12.71 $26.11 $27.66 $41.08 Plan 411 $20.27 $55.07 $20.27 $39.30 $64.78 $20.27 $41.64 $44.19 $65.55 Plan 412 $57.17 $41.09 $67.11 $43.62 $45.57 $67.97 Plan 413 $21.44 $57.64 $21.44 $41.44 $67.62 $21.44 $44.00 $45.92 $68.48 Plan 414 $20.52 $55.08 $20.52 $39.67 $64.60 $20.52 $42.17 $43.80 $65.44 Plan 415 $17.20 $46.16 $17.20 $33.28 $54.09 $17.20 $35.39 $36.62 $54.81 Plan 416 $19.03 $50.30 $19.03 $36.65 $58.70 $19.03 $39.11 $39.49 $59.58 Plan 430 $16.99 $46.24 $16.99 $32.94 $54.43 $16.99 $34.88 $37.16 $55.06 Plan 431 $13.06 $38.91 $13.06 $25.82 $47.01 $13.06 $26.58 $33.57 $47.08 Plan 432 $12.76 $35.92 $12.76 $24.97 $42.70 $12.76 $26.18 $29.61 $43.02 Area 2 - Baker, Bradford, Calhoun, DeSoto, Dixie, Franklin, Gadsden, Gilchrist, Glades, Hamilton, Hardee, Hendry, Holmes, Jefferson, Lafayette, Levy, Liberty, Madison, Okeechobee, Putnam, Sumter, Suwannee, Taylor, Union, Wakulla, Washington $20.56 $55.26 $20.56 $39.76 $64.81 $19.66 $52.87 $19.66 $38.05 $62.01 $12.46 $33.84 $12.46 $24.17 $39.80 $53.99 $38.53 $63.51 $20.82 $56.05 $20.82 $40.28 $65.79 $21.02 $56.51 $21.02 $40.63 $66.29 $20.12 $54.00 $20.12 $38.89 $63.33 $16.86 $45.25 $16.86 $32.63 $53.03 $18.66 $49.31 $18.66 $35.93 $57.55 $45.33 $32.29 $53.36 $12.80 $38.15 $12.80 $25.31 $46.09 $12.51 $35.22 $12.51 $24.48 $41.86 $20.56 $42.24 $43.97 $65.64 $19.66 $40.43 $42.06 $62.82 $12.46 $25.60 $27.12 $40.27 $40.82 $43.32 $64.26 $20.82 $42.76 $44.68 $66.64 $21.02 $43.14 $45.02 $67.14 $20.12 $41.34 $42.94 $64.16 $16.86 $34.70 $35.90 $53.74 $18.66 $38.34 $38.72 $58.41 $34.20 $36.43 $53.98 $12.80 $26.06 $32.91 $46.16 $12.51 $25.67 $29.03 $42.18 Area 3 - Brevard, Charlotte, Indian River, Lee, Manatee, Martin, St. Lucie, Sarasota $23.70 $63.68 $22.66 $60.93 $14.36 $38.99 $22.90 $62.21 $24.00 $64.59 $24.22 $65.12 $23.18 $62.23 $19.43 $52.15 $21.51 $56.82 $19.20 $52.23 $43.97 $14.41 $40.59 $23.70 $45.82 $74.68 $22.66 $43.85 $71.46 $14.36 $27.85 $45.86 $22.90 $44.40 $73.19 $24.00 $46.42 $75.81 $24.22 $46.82 $76.39 $23.18 $44.82 $72.98 $19.43 $37.61 $61.11 $21.51 $41.40 $66.32 $19.20 $37.21 $61.49 $29.17 $53.11 $14.41 $28.21 $48.24 $23.70 $48.68 $50.67 $75.64 $22.66 $46.59 $48.47 $72.40 $14.36 $29.50 $31.26 $46.41 $22.90 $47.04 $49.92 $74.05 $24.00 $49.28 $51.49 $76.79 $24.22 $49.72 $51.88 $77.37 $23.18 $47.64 $49.48 $73.94 $19.43 $39.99 $41.37 $61.93 $21.51 $44.18 $44.62 $67.31 $19.20 $39.42 $41.98 $62.20 $30.03 $37.93 $53.19 $14.41 $29.58 $33.45 $48.61 Area 4 - Broward, Collier, Miami-Dade, Monroe, Palm Beach $26.86 $72.04 $25.78 $69.17 $16.34 $44.27 $25.99 $70.41 $27.21 $73.10 $27.47 $73.70 $22.00 $58.94 $22.15 $59.35 $24.38 $64.29 $21.86 $59.34 $16.96 $50.21 $16.41 $46.09 $26.86 $51.90 $84.46 $25.78 $49.83 $81.09 $16.34 $31.66 $52.06 $25.99 $50.32 $82.80 $27.21 $52.59 $85.75 $27.47 $53.06 $86.43 $26.28 $50.77 $82.53 $22.00 $42.53 $69.06 $24.38 $46.91 $75.02 $21.86 $42.35 $69.82 $16.96 $33.43 $60.58 $16.41 $32.07 $54.74 $26.86 $55.16 $57.28 $85.57 $25.78 $52.97 $54.96 $82.16 $16.34 $33.57 $35.47 $52.69 $25.99 $53.32 $56.46 $83.78 $27.21 $55.85 $58.22 $86.86 $27.47 $56.36 $58.65 $87.55 $26.28 $53.96 $55.94 $83.63 $22.00 $45.24 $46.74 $70.00 $24.38 $50.07 $50.46 $76.15 $21.86 $44.86 $47.64 $70.64 $16.96 $34.47 $43.17 $60.69 $16.41 $33.66 $37.94 $55.19 Out-of-Network coinsurance is paid based upon the In-Network dentist fee schedule Refer to Underwriting guidelines attached. Restricted Industries require a minimum group size of 10 and underwriting approval. 4-9 life groups in Restricted Industries are only eligible for BlueDental Care (prepaid) plans, when located in counties where this product is marketed. 6
Plans Rollover and Ortho rates are shown on page 9. BlueDental Choice PPO Community Rated Plans Rates Effective 10/15/2011 Plan 451 Group Plans (No Employer Contribution Required) Plan 454 Plan 460 In-Network Coinsurance Percentage 100/80/50 100/80/50 80/60/40 100/80/50 100/80/50 100/80/50 100/80/50 100/60/50 80/80/50 100/80/50 100/80/0 100/50/25 Out-of-Network Coinsurance Percentage 80/60/40 80/60/40 70/50/30 100/50/25 90/60/40 80/70/40 80/50/40 80/40/30 60/60/40 70/50/30 100/80/0 80/50/25 Employer Contribution (Minimum required for Dental) 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% Minimum Participation % or # of lives, whichever is greater Deductible Individual/ $50/$150 $75/$225 $75/$225 $50/$150 $50/$150 $50/$150 $50/$150 $50/$150 $50/$150 $75/$225 $75/$225 $75/$225 Plan Year Maximum $1,000 $1,000 $750 $1,000 $1,000 $1,000 $1,000 $1,000 $1,000 $750 $750 $1,000 Endo/Perio Covered as Major Major Major Major Major Major Major Major Major Major Major Major Plan 461 Plan 462 Plan 463 Plan 464 Plan 465 Plan 466 Plan 480 Plan 481 Plan 482 Area 1 - Alachua, Bay, Citrus, Clay, Columbia, Duval, Escambia, Flagler, Gulf, Hernando, Highlands, Hillsborough, Jackson, Lake, Leon, Marion, Nassau, Okaloosa, Orange, Osceola, Pasco, Pinellas, Polk, St. Johns, Santa Rosa, Seminole, Volusia, Walton $53.56 $38.01 $63.15 $18.64 $51.15 $18.64 $36.28 $60.32 $11.70 $32.53 $11.70 $22.84 $38.51 $18.83 $52.25 $18.83 $36.75 $61.82 $19.80 $54.38 $19.80 $38.54 $64.15 $19.86 $54.59 $19.86 $38.67 $64.40 $19.22 $52.54 $19.22 $37.35 $61.90 $45.05 $32.27 $52.93 $47.51 $34.14 $55.77 $15.50 $43.33 $15.50 $30.31 $51.37 $10.31 $33.57 $10.11 $20.54 $40.54 $11.75 $33.97 $11.75 $23.16 $40.62 $40.20 $43.19 $63.84 $18.64 $38.37 $41.25 $60.99 $11.70 $24.07 $26.50 $38.87 $18.83 $38.73 $42.53 $62.41 $19.80 $40.74 $43.91 $64.85 $19.86 $40.87 $44.09 $65.09 $19.22 $39.55 $42.29 $62.62 $34.24 $35.96 $53.59 $36.23 $37.86 $56.49 $15.50 $31.90 $35.42 $51.83 $10.11 $20.63 $29.79 $40.31 $11.75 $24.14 $28.44 $40.84 Area 2 - Baker, Bradford, Calhoun, DeSoto, Dixie, Franklin, Gadsden, Gilchrist, Glades, Hamilton, Hardee, Hendry, Holmes, Jefferson, Lafayette, Levy, Liberty, Madison, Okeechobee, Putnam, Sumter, Suwannee, Taylor, Union, Wakulla, Washington $52.51 $37.26 $61.91 $18.27 $50.15 $18.27 $35.57 $59.14 $11.47 $31.89 $11.47 $22.39 $37.75 $51.23 $36.03 $60.61 $53.31 $37.78 $62.89 $19.47 $53.52 $19.47 $37.91 $63.14 $18.84 $51.51 $18.84 $36.62 $60.69 $44.17 $31.64 $51.89 $17.27 $46.58 $17.27 $33.47 $54.68 $15.20 $42.48 $15.20 $29.72 $50.36 $10.11 $32.91 $12.11 $24.62 $48.60 $11.52 $33.30 $11.52 $22.71 $39.82 $39.41 $42.34 $62.59 $18.27 $37.62 $40.44 $59.79 $11.47 $23.60 $25.98 $38.11 $37.97 $41.70 $61.19 $39.94 $43.05 $63.58 $19.47 $40.07 $43.23 $63.81 $18.84 $38.77 $41.46 $61.39 $33.57 $35.25 $52.54 $17.27 $35.52 $37.12 $55.38 $15.20 $31.27 $34.73 $50.81 $12.11 $24.73 $35.71 $48.33 $11.52 $23.67 $27.88 $40.04 Area 3 - Brevard, Charlotte, Indian River, Lee, Manatee, Martin, St. Lucie, Sarasota $22.06 $60.51 $21.05 $57.79 $13.21 $36.75 $21.28 $59.04 $22.37 $61.44 $22.44 $61.67 $21.71 $59.36 $50.90 $19.90 $53.68 $17.51 $48.95 $11.65 $37.93 $13.27 $38.37 $22.06 $42.94 $71.34 $21.05 $40.99 $68.15 $13.21 $25.81 $43.50 $21.28 $41.52 $69.84 $22.37 $43.54 $72.47 $22.44 $43.69 $72.76 $21.71 $42.20 $69.94 $36.46 $59.79 $19.90 $38.57 $63.02 $17.51 $34.25 $58.03 $11.65 $23.67 $46.72 $13.27 $26.17 $45.88 $22.06 $45.42 $48.79 $72.13 $21.05 $43.35 $46.60 $68.90 $13.21 $27.20 $29.94 $43.92 $21.28 $43.75 $48.05 $70.52 $22.37 $46.03 $49.61 $73.27 $22.44 $46.17 $49.81 $73.54 $21.71 $44.67 $47.78 $70.74 $38.69 $40.63 $60.55 $19.90 $40.94 $42.78 $63.82 $17.51 $36.04 $40.03 $58.55 $11.65 $23.77 $34.33 $46.45 $13.27 $27.28 $32.13 $46.14 Area 4 - Broward, Collier, Miami-Dade, Monroe, Palm Beach $24.94 $68.31 $24.94 $48.50 $80.53 $24.94 $51.30 $55.07 $81.42 $23.86 $65.47 $23.86 $46.46 $77.19 $23.86 $49.14 $52.78 $78.04 $14.98 $41.65 $14.98 $29.26 $49.27 $14.98 $30.83 $33.90 $49.75 Out-of-Network coinsurance is paid based upon the In-Network dentist fee schedule Refer to Underwriting guidelines attached. Restricted Industries require a minimum group size of 10 and underwriting approval. 4-9 life groups in Restricted Industries are only eligible for BlueDental Care (prepaid) plans, when located in counties where this product is marketed. 7 $24.05 $66.67 $24.05 $46.91 $78.84 $24.05 $49.44 $54.23 $79.62 $25.28 $69.37 $25.28 $49.18 $81.82 $25.28 $51.98 $56.00 $82.71 $25.36 $69.63 $25.36 $49.35 $82.14 $25.36 $52.15 $56.24 $83.03 $24.52 $67.02 $24.52 $47.68 $78.96 $24.52 $50.45 $53.93 $79.86 $57.45 $41.19 $67.50 $43.71 $45.86 $68.34 $22.48 $60.59 $22.48 $43.54 $71.11 $22.48 $46.24 $48.27 $72.02 $55.47 $38.83 $65.74 $40.85 $45.35 $66.34 $13.26 $43.07 $13.26 $26.93 $53.03 $13.26 $27.07 $38.93 $52.74 $15.06 $43.47 $15.06 $29.68 $51.97 $15.06 $30.94 $36.39 $52.27
BlueDental Choice PPO - BlueDental Choice Copayment PPO Community Rated Plans Rates Effective 10/15/2011 Underwriting Guidelines Community Rated Plans are sold as single option only. Deductible - Deductible does not apply to Preventive services for any BlueDentalChoice or Choice Copayment plan (nor to Ortho if selected). - In-Network deductible credits apply to Out-of-Network deductible and Out-of-Network deductible credits apply to In-Network deductible. Waiting Periods If an existing comparable dental plan is being replaced: - For plans no waiting period applies to Major and Orthodontic services. - For Group plans a 12-month waiting period for Major and Orthodontic services applies to enrollees not covered under the prior plan. If the prior plan does not include any orthodontic benefits but orthodontic benefits are sold under the new plan, a 12-month waiting period will apply to Orthodontic Services. If an existing comparable dental plan is not being replaced, or if no dental plan is currently inforce, a 12-month waiting period applies to Major and Orthodontic services. DHMO/Prepaid dental plans will be treated as comparable for this product. Scheduled and discount plans are not comparable. Out-of-Network coinsurance is paid based upon the In-Network dentist fee schedule. The copayment fees on the BlueDental Choice Copayment Plans will not apply toward the satisfaction of any deductible or coinsurance requirements under the contract. Plan effective dates are the 1st and 15th of the month. Plan designs included in this brochure are also available and require Home Office rating for: - Groups greater than 50 lives - Groups that are in any of the 9 SIC codes that can t be rated in accessblue - 4-9 life groups in Restricted Industries are only eligible for BlueDental Care (prepaid) plans, when located in counties where this product is marketed. - Groups that meet requirements for dual option plan coverage The following restricted industries do not qualify for Community Rates; however, they can be rated and quoted Choice and Choice Copayment plans on accessblue for groups of 10 or more lives. 8 Restricted Industries SIC Codes Industry 5093 Scrap and Waste Materials 5813 Drinking Establishments 6021-6082 Banks and Credit Unions 7812, 7819, 7822, 7829 Motion Picture & Video Production, Service & Distribution 7911 Dance Studios 7922-7929 Theatrical Producers and Services and Entertainers 7948, 7991 Sports, Amusements, Physical Fitness Facilities 7993 Amusement and Recreation 8011-8099 Medical and Dental Facilities, Hospitals, Labs 8111 Legal Services 8211-8299 Schools, Colleges, Universities 9111-9661 Public Administration 9711, 9721 National Security, International Affairs Area Rating: Choice PPO Premiums vary based on three areas in FL. Area 1 Counties Alachua, Bay, Citrus, Clay, Columbia, Duval, Escambia, Flagler, Gulf, Hernando, Highlands, Hillsborough, Jackson, Lake, Leon, Marion, Nassau, Okaloosa, Orange, Osceola, Pasco, Pinellas, Polk, St. Johns, Santa Rosa, Seminole, Volusia, Walton Area 2 Counties Baker, Bradford, Calhoun, DeSoto, Dixie, Franklin, Gadsden, Gilchrist, Glades, Hamilton, Hardee, Hendry, Holmes, Jefferson, Lafayette, Levy, Liberty, Madison, Okeechobee, Putnam, Sumter, Suwannee, Taylor, Union, Wakulla, Washington Area 3 Counties Brevard, Charlotte, Indian River, Lee, Manatee, Martin, St. Lucie, Sarasota Area 4 Counties Broward, Collier, Miami-Dade, Monroe, Palm Beach Orthodontic Benefits (Optional) Minimum of 5 child/family units enrolled No deductible 50% coinsurance benefit Children covered until 19th birthday Orthodontic Lifetime Benefit Maximum cannot exceed Plan Year Benefit Maximum See Underwriting Guidelines for possible Waiting Period. Orthodontic benefits can not be added unless the plan provides coverage for Major Services The following restricted industries do not qualify for Community Rates and cannot be quoted on accessblue. They require Home Office rating and approval: SIC Codes Industry 7941 Sports Clubs, Managers and Promoters 7996 Amusement Parks 7999 Amusement and Recreation, NEC 8021 Office and Clinics of Dentists 8072 Dental Laboratories 8641 Civic and Social Associations 8811 Private Households 8999 Services not elsewhere classified 9999 Non-Classifiable
Annual Maximum Rollover Rider Premiums for Choice & Copayment Annual Maximum $500 -$749 $750 - $999 $1,000 - $1,249 $1,250 - $1,499 $1,500 - $1,999 Rollover Threshold $200 $300 $500 $600 $700 Annual Rollover Amount $150 $200 $350 $450 $500 Accumulated Rollover Max $500 $500 $1,000 $1,250 $1,250 Orthodontic Rates: BlueDental Choice Copayment PPO see Copayment Plan matrix on page 2. BlueDental Choice PPO Tier Level Ortho Lifetime Max Ortho Lifetime Max $750 $1,000 $750 $1,000 Community Rated Premiums Two Tier $0.62 $1.78 $0.51 $1.48 $0.36 $1.05 $0.16 $0.47 $0.08 $0.24 Two Tier $0.09 $0.11 $0.11 $0.13 $4.16 $5.02 $4.97 $6.00 Three Tier $0.09 $0.11 $0.11 $0.13 $0.90 $1.09 $1.07 $1.30 Three Tier $0.62 $1.22 $2.14 $0.51 $1.01 $1.77 $0.36 $0.72 $1.26 $0.16 $0.32 $0.57 $0.08 $0.16 $0.29 $6.17 $7.44 $7.37 $8.89 Four Tier $0.09 $0.11 $0.11 $0.13 $0.18 $0.22 $0.22 $0.26 Four Tier $0.62 $1.26 $1.36 $2.20 $0.51 $1.05 $1.13 $1.82 $0.36 $0.74 $0.80 $1.30 $0.16 $0.34 $0.36 $0.58 $0.08 $0.17 $0.18 $0.29 $5.66 $6.83 $6.76 $8.16 $5.75 $6.94 $6.86 $8.29 9