Horizon Centurion Dental P.O. Box 1471 Minneapolis, MN 55440-1471 HorizonBlue.com/Dental

2430 (W1112) 9236 Kit (W0616)

An Independent Licensee of the Blue Cross and Blue Shield Association.

Affordable Dental Benefits

Dear Valued Customer:

Are you looking for an affordable individual dental program? Do you have a friend, family member or business associate who is looking for affordable individual dental coverage?

If so, Horizon Blue Cross Blue Shield of New Jersey offers the Horizon Centurion Dental Program to meet your dental care needs. The Horizon Centurion Dental Program is an ideal way for people who do not have dental insurance to get affordable dental care.

The Horizon Centurion Dental Program offers reduced fees to members when they receive eligible dental services from a participating dentist. These dentists have agreed to accept fees up to 30 percent less than normal for all eligible dental services. When members use these dentists, they will only need to pay the dentist the reduced fee.

To learn more about how the Horizon Centurion Dental Program can help you, please review the enclosed information. The fees included on the Horizon Centurion Savings Schedule are for services provided by a participating general dentist; fees for specialists are generally higher. Call 1-800-4DENTAL (1-800-433-6825) for more information on specialists’ fees.

Don’t delay. Submit your application with your payment by the 15th of the month and enjoy affordable dental care from the Horizon Centurion Dental Program effective the first of the following month.

Sincerely,

John A. Selby Director Consumer, Senior and Dental Markets Horizon BCBSNJ

Answers to frequently asked questions about the Horizon Centurion Dental Program

See plan document for a complete description, including limitations, exclusions and waiting periods.

Services and products provided by Horizon Blue Cross Blue Shield of New Jersey.Horizon BCBSNJ provides administrative claims reimbursement services only and does not assume financial risk or obligation with respect to claims.The Blue Cross® and Blue Shield® names and symbols are registered marks of the Blue Cross and Blue Shield Association. The Horizon® name, symbols and Making Healthcare Work® are registered marks of Horizon Blue Cross Blue Shield of New Jersey. © 2013 Horizon Blue Cross Blue Shield of New Jersey, Three Penn Plaza East, Newark, New Jersey 07105-2200.

Questions & AnswersAQ&

How does the program work?The Horizon Centurion Dental Program is anaffordable individual dental program. When youvisit a participating Horizon Dental PPO dentist foreligible services and show your Horizon CenturionDental Program ID card, you receive those servicesat reduced fee levels.

Will I be required to visit certain dentists?Yes. Only dentists who participate in theHorizon Dental PPO Network honor this program. Simply visit one of these dentists toreceive the reduced fees, and enjoy our extensive network of participating dentistslocated throughout New Jersey.

What if I need specialty care?If you require specialty care, simply visit one ofthe participating specialists. Note that the feesincluded on the Horizon Centurion DentalProgram Savings Schedule are for services rendered by a participating general dentist; feesfor specialists will generally be higher.

Will I be required to fill out a claim form when Ihave services rendered under the HorizonCenturion Dental Program?No. There are never any claim forms to file.When you receive eligible dental services from aparticipating Horizon Dental PPO Network dentist,simply pay the dentist the reduced fees at the timeof service.

Will there be any changes in the reduced dentalfees payable under the Horizon CenturionDental Program?The reduced dental fees applicable under theHorizon Centurion Dental Program are subjectto change in the future. We reserve the right tochange fees once per contract year with 30-daysnotice. Participants are responsible for the feesapplicable at the time services are rendered.

What do I do if I need emergency treatment?Always seek appropriate care. However, if careis not rendered by a participating HorizonDental PPO Network dentist, you will notreceive the reduced rates and will be requiredto pay the dentist’s fees in full.

What if I am out of state and need to see a dentist?You may visit any dentist you wish. However, ifthat dentist is not a participating Horizon DentalPPO Network dentist, you will not receive thereduced rates and will be required to pay thedentist’s fees in full.

When will my next payment for the HorizonCenturion Dental Program be due?The Horizon Centurion Dental Program is anannual program. To continue your enrollmentin the program, you will be billed 45 days priorto the anniversary of your initial enrollment.Horizon Blue Cross Blue Shield of New Jerseymust receive payment by the 15th of the monthprior to the effective date.

19797 (W0313)

Horizon Centurion Dental Plan Patient Savings Schedule For New Jersey Dentists

When you receive treatment from dentists in the Horizon Dental PPO Network, your costs are reduced significantly. This Patient Savings Schedule compares the chargesyou will pay for eligible services under the Horizon Centurion Dental Plan with typical charges* and illustrates the savings you might expect.

The fees listed below represent charges when using Horizon Dental PPO Network general dentists. Fees charged by specialists (also reduced) will generally be higher.Call 1-800-4DENTAL (1-800-433-6825) for information on specialists’ fees.

BenefitsProcedureCode Description

D0150 Comprehensive oral evaluation $39 $98 $59D0120 Periodic oral evaluation $23 $56 $33

ORAL EXAMS

D0210 Intraoral – complete series (including bitewings) $62 $140 $78D0220 Intraoral – single film $9 $28 $19D0230 Intraoral – each additional film $5 $25 $20D0240 Intraoral – occlusal, single film $14 $44 $30D0272 Bitewing – two films $13 $50 $37D0274 Bitewing – four films $18 $70 $52D0330 Panoramic film $47 $123 $76

X-RAYS

D0460 Pulp vitality tests $14 $45 $31D1110 Prophylaxis – adult $59 $106 $47D1120 Prophylaxis – child $36 $73 $37D1208 Topical fluoride $15 $45 $30D1351 Sealants, per tooth $26 $53 $27

PREVENTIVE

D1510 Fixed, unilateral $106 $365 $259D1515 Fixed, bilateral $147 $511 $364D1520 Removable, unilateral $113 $402 $289D1525 Removable, bilateral $147 $621 $474D1550 Recementation of space maintainer $23 $79 $56

SPACE MAINTAINERS

You Pay

TypicalCharge*

TypicalSavings Benefits

ProcedureCode Description

TREATMENT AND THERAPY

You Pay

TypicalCharge*

TypicalSavings

D2140 One surface, permanent or primary tooth $49 $140 $91D2150 Two surfaces, permanent or primary tooth $72 $181 $109D2160 Three surfaces, permanent or primary tooth $89 $218 $129D2161 Four or more surfaces, permanent or

primary tooth $112 $266 $154

ORAL SURGERY

D7140 Routine extractions $63 $201 $138

AMALGAM

D2330 One surface, anterior tooth $68 $152 $84D2331 Two surfaces, anterior tooth $85 $194 $109D2332 Three surfaces, anterior tooth $105 $237 $132D2391 One surface, posterior tooth $80 $178 $98D2392 Two surfaces, posterior tooth $84 $233 $149D2393 Three surfaces, posterior tooth $120 $289 $169

COMPOSITE RESIN

D7220 Soft tissue $139 $399 $260D7230 Partially bony $219 $531 $312D7240 Completely bony $292 $624 $332D7310 Alveoloplasty (in conjunction with

extractions, per quadrant) $76 $390 $314D7510 Incision and drainage of abscess – intraoral $47 $419 $372

EXTRACTION OF IMPACTED TEETH

Horizon Centurion Dental Plan

BenefitsProcedureCode Description

PROSTHODONTICS

You Pay

TypicalCharge*

TypicalSavings

* Based on the 75th percentile of 2013 Fair Health Relative Value Benchmarks (FHRVB). Typical charges areprovided for illustrative purposes only. Actual charges will vary. Consult your contract or benefits bookletfor detailed plan descriptions and limitations.

This is a brief description of the most common dental services available. Actual covered services may vary by contract. For information on any procedure not shown in this schedule, please call 1-800-4DENTAL.

The fees shown are effective January 1, 2013 and are subject to change at any time.

BenefitsProcedureCode Description

ENDODONTICS

You Pay

TypicalCharge*

TypicalSavings

D3110 Pulp cap – direct (excluding final restoration) $18 $99 $81D3220 Therapeutic pulpotomy

(excluding final restoration) $68 $203 $135

PERIODONTICS

D4260 Osseous surgery – per quadrant $534 $1,421 $887D4270 Pedicle soft tissue grafts $226 $1,003 $777D4271 Free soft tissue graft $226 $1,040 $814D4341 Periodontal scaling and root planing

(per quadrant) $98 $254 $156

GENERAL SERVICES

D9110 Palliative (emergency) treatment of dental pain minor procedures $42 $121 $79

D9220 General anesthesia (first 30 minutes) $64 $380 $316

D3310 Anterior teeth, excludes final restoration $378 $810 $432D3320 Premolars, excludes final restoration $470 $992 $552D3330 Molars, excludes final restoration $573 $1,230 $657D3410 Apicoectomy – anterior $227 $931 $704D3430 Retrograde filling, per root $60 $291 $231D3920 Hemisection (including any root removal) $113 $461 $348

ROOT CANAL THERAPY

D5110 Complete upper $770 $1,456 $686D5120 Complete lower $770 $1,456 $686D5130 Immediate upper $770 $1,587 $817D5140 Immediate lower $770 $1,587 $817D5211 Upper – partial resin base (including any

conventional clasps, rests and teeth) $461 $1,229 $768D5212 Lower – partial resin base (including any

conventional clasps, rests and teeth) $461 $1,428 $967

DENTURES

ONLAYS AND CROWNS

D2543 Metallic, three surfaces $314 $1,479 $1,165D2544 Four or more surfaces $467 $1,538 $1,071

ONLAY

D2750 Porcelain fused to high noble metal $681 $1,202 $521D2790 Full cast high noble metal $681 $1,160 $479D2780 3/4 cast high noble metal $618 $1,113 $495D2910 Recement inlays $27 $111 $84D2920 Recement crowns $27 $113 $86

CROWNS

D5510 Repair broken complete denture base $67 $159 $92D5520 Repair missing or broken teeth – each tooth $54 $133 $79D5610 Repair resin denture base $64 $173 $109D5620 Repair cast framework $69 $186 $117D5630 Repair or replace broken clasp $58 $226 $168

DENTURE REPAIR

D6240 Pontic – porcelain fused to high noble metal $681 $1,112 $431D6750 Abutment crowns, porcelain fused

to high noble metal $681 $1,162 $481D6930 Recement bridgework $46 $176 $130

FIXED BRIDGEWORK

Services and products provided by Horizon Blue Cross Blue Shield of New Jersey.Horizon BCBSNJ provides administrative claims reimbursement services only and does not assume financial risk or obligation with respect to claims.The Blue Cross® and Blue Shield® names and symbols are registered marks of the Blue Cross and Blue Shield Association. The Horizon® name, symbols and Making Healthcare Work® are registered marks of Horizon Blue Cross Blue Shield of New Jersey. © 2013 Horizon Blue Cross Blue Shield of New Jersey, Three Penn Plaza East, Newark, New Jersey 07105-2200. 19676 (W0113)

P.O. Box 1471 Minneapolis, MN 55440-1471 1-800-4DENTAL www.HorizonBlue.com

HORIZON CENTURION DENTAL PROGRAM APPLICATION FOR ENROLLMENT

Name

First Middle Initial Last

Address Street City State Zip

Home Phone Work Phone Email Area Code Area Code

ELIGIBLE PERSONS TO BE ENROLLED Complete this box for yourself and all dependents enrolling. Attach another application if you have more than four children. (Note: Dependent children are covered under a parent’s contract only until they reach the contract termination age of 23.)

DATE OF BIRTH GENDER SOCIAL SECURITY FIRST MI LAST MO DAY YR M/F NUMBER

Applicant

Spouse/Domestic Partner/Civil Union Partner (circle one)

Child

Child

Child

Legal Ward

Enroll today in the Horizon Centurion Dental Program Select One

1 Individual – Total amount due $60.00 per year 1 Family – Total amount due $84.00 per year (2 Adults or Adult(s) & Dependent Child(ren) See Terms and Limitations)

Select One Payment Option Payment enclosed. Make check or money order payable to: Horizon Healthcare Dental Services, Inc. When you

provide a check as payment, you authorize us either to use the information from your check to make a one-time electronic fund transfer from your account or to process the payment as a check transaction.

Direct Withdrawal from Checking/Savings Account Name on Account ____________________________________________ Bank Name ___________________________________________ Routing Number ____________________________________ Account Number _________________________________

Select One: Credit Card Debit Card MasterCard ® Visa ® Credit/Debit Card Number _____________________________________ Exp. Date _____/_____ Security Code _____ Name As It Appears On Credit/Debit Card _______________________________________________________________

I hereby apply for participation. I understand and agree that any benefits provided pursuant to this application will be at the level of discounts indicated. I hereby accept responsibility for payment of the discounted charges. I understand that services must be provided by a Horizon Dental PPO dentist in order to receive any discount. We reserve the right to change fees once per contract year with 30 days notice. I further acknowledge that dentist’s fees under the Horizon Centurion Dental Program are subject to change and, that I will be responsible for the fees in effect at the time of service. I further acknowledge that participation shall become effective only if approved and services are rendered on or after the effective date of participation which will be the first of the next month provided payment is received by the 15th of the current month. I certify to the best of my knowledge and believe the information given on this application is complete and true. I understand that my participation may be cancelled without written prior notice if I have included false information. I also understand that such termination will be retroactive to the date of my participation. Signature __________________________________________________________ Date _________________ Services and products may be provided by Horizon Blue Cross Blue Shield of New Jersey or Horizon Healthcare Dental, Inc. each of which is an independent licensee of the Blue Cross and Blue Shield Association. Horizon Healthcare Dental, Inc. is a subsidiary of Horizon Blue Cross Blue Shield of New Jersey. WHITE COPY – HBCBSNJ DENTAL PROGRAMS YELLOW COPY – APPLICANT/SPONSOR CEN 1.17.13

HORIZON  CENTURION  TERMS  AND  LIMITATIONS    

1. Eligible dependents under a family program include the participant’s spouse/domestic partner/civil union partner and/or one or more of the participant’s eligible child dependents. Eligible child dependents include natural born children or stepchildren of the participant or the participant’s spouse/domestic partner/civil union partner, legally adopted children of the participant or the participant’s spouse/domestic partner/civil union partner, a child for whom the participant or the participant’s spouse/domestic partner/civil union partner has legal guardianship over and who is wholly dependent upon the participant or the participant’s spouse/domestic partner/civil union partner for most of his/her support and maintenance, and the participant or the participant’s spouse/domestic partner /civil union partner foster children. Proof of support or adoption and all other matters pertaining to eligibility as a child dependent must be submitted to Horizon Blue Cross Blue Shield of New Jersey Dental Programs when requested.

2. Eligible child dependents are covered through the end of the month in which they turn age 23.

3. A child otherwise defined above but who has obtained age 23 and who Horizon Blue Cross Blue Shield of

New Jersey Dental Programs determines is incapable of self-sustaining employment by reason of mental or physical handicap or developmental disability shall be considered a child under this program if he/she depends on the participant or the participant’s spouse/domestic partner/civil union partner for support and maintenance and had the condition before attaining age 23. Proof of handicap must be submitted to Horizon Blue Cross Blue Shield of New Jersey Dental Programs when requested.

4. Payment for the Horizon Centurion program is made on an annual basis. No mid term refunds or

adjustments (i.e., family to single) will be allowed.

5. Negotiated charge levels are only available when services are rendered by a Horizon Blue Cross Blue Shield of New Jersey Dental Programs participating PPO dentist.

6. The negotiated charge levels are subject to change in the future. Changes will occur no more than once during any twelve month period and participants will be notified 30 days in advance of any changes.

7. Services for which Horizon Blue Cross Blue Shield of New Jersey Dental Programs has not negotiated a discounted charge with the PPO dentists may be billed at the Dentists usual charge.

8. No person, other than the participant and his/her eligible dependents is entitled to receive the negotiated

charges under this program. This program is not transferable.

9. This program provides discounted charges for most Dental services when the participant uses a Horizon Dental PPO provider. The participant is responsible for paying all discounted charges. No payments will be made by Horizon Blue Cross Blue Shield of New Jersey Dental Programs for services rendered under this program.

Three Penn Plaza East Newark, NJ 07105-2200 HorizonBlue.com

CMC0008179 (0616)

An Independent Licensee of the Blue Cross and Blue Shield Association.

Notice of Nondiscrimination Horizon Blue Cross Blue Shield of New Jersey complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability or sex. Horizon BCBSNJ does not exclude people or treat them differently because of race, color, national origin, age, disability or sex. Horizon BCBSNJ provides free aids and services to people with disabilities to communicate effectively with us, such as:

• Qualified sign language interpreters • Information written in other languages

If you need these services, contact Horizon BCBSNJ’s Director of Regulatory Compliance at the phone number, fax or email listed below. If you believe that Horizon BCBSNJ has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability or sex, you can file a grievance with: Horizon BCBSNJ – Director, Regulatory Compliance Three Penn Plaza East, PP-16C Newark, NJ 07105 Phone: 1-800-658-6781 Fax: 1-973-466-7759 Email: ComplianceAndEthicsOffice@HorizonBlue.com You can file a grievance in person, or by mail, fax or email. If you need help filing a grievance, Horizon BCBSNJ’s Director of Regulatory Compliance is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: Office for Civil Rights Headquarters U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 1-800-368-1019 or 1-800-537-7697 (TDD) Complaint forms are available at www.hhs.gov/ocr/office/file/index.html.

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