037464 (04-2017)

Highlights of your Dental Coverage Effective Date: 07/01/2017Any deductibles, copays, and coinsurance percentages shown are amounts for which you're responsible.

DENTAL PLAN PREMERA PREFERRED CHOICE: DENTAL OPTIMA - $1,500 MAXIMUMCOVERED SERVICES

Individual/Family Deductible PCY $50 PCY / $150 PCY

Diagnostic/Preventive Covered In Full

-cleanings (limited to 2 PCY)-emergency exams (unlimited)-fluoride treatments (limited to 2 applications PCY, age limits apply)-routine oral exams (limited to 2 PCY)-routine x-rays (complete series or panoramic x-ray once per 36 consecutive months)-sealants (limited to permanent teeth, age limits apply) -space maintainers (age limits apply)

Basic Deductible, then 20%

-emergency palliative treatment-endodontic (root canal) treatment (limited to 2 per arch when performed in conjunction with overdentures)-fillings (limited to once per tooth surface every 24 consecutive months)-full mouth debridement-general anesthesia (limited to covered dental procedures at a dental-care provider's office when dentally necessary)-oral surgery (including simple and surgical extractions)-periodontal maintenance (limited to 4 visits per calendar year)-periodontal scaling (limited to 2 every 12 consecutive months)-periodontal surgery-repair & recementing of crowns, inlays, bridgework & dentures

Major Deductible, then 50%

-implants, dentures, partial & fixed bridges (replacements limited to once every 5 calendar years)-inlays, onlays & crowns (replacements limited to once per tooth every 5 years)

Annual Maximum $1,500 PCY applies to basic and major services

Annual deductible waived for Diagnostic/Preventive services

PCY = Per Calendar Year. Balance billing may apply if a provider is not contracted with Premera Blue Cross. Members are responsible for amounts in excess of the allowable charge.

This is not a complete explanation of covered services, exclusions, limitations, reductions or the terms under which the program may be continued in force. This benefit highlight is not a contract. For full coverage provisions, including a description of waiting periods, limitations and exclusions please contact Customer Service.

Definitions

Below is a list of commonly used healthcare terms. At Premera, our goal is to make using your health plan easy. This is just one of the ways we care for you.

aggregate deductible

There is one deductible for the subscriber (individual) and his/her family that must be met first, before anyone in the family is covered for services. The family out of-pocket maximum is aggregate.

allowable amount*

The amount that an in-network provider agrees to charge for healthcare services or supplies. When you receive services from in-network providers, you’ll be responsible only for any applicable cost sharing, including deductibles, copays, coinsurance, and charges in excess of the stated benefit.

coinsurance

Your percentage of the cost for a service. If your plan’s coinsurance is 20%, you pay 20% of the allowed amount and your plan pays the other 80%.

copay

This is a flat fee you pay for a specific service (like an office visit) at the time you receive the service.

covered in full

This means your plan pays the full cost for a service. You do not pay deductibles, coinsurance, or copays for services that are covered in full.

deductible

The amount of money you pay in medical costs before your health plan begins to pay.

drug list

A list of prescription drugs, both generic and brand name. Not all drugs are included in every drug list.

network

A group of doctors, dentists, pharmacies, hospitals, and other healthcare providers that contract with Premera to provide services and supplies at negotiated amounts called allowable amounts.

out-of-pocket maximum

The maximum amount of cost shares you will pay for covered services in a calendar year. After you’ve met your out-of-pocket maximum, the plan pays 100% for in-network services for the rest of the year.

primary care provider (PCP)

The doctor or other healthcare provider you designate to provide most of your healthcare needs. You can choose a different primary care provider for each family member. Your primary care doctor can be a family practice physician, general practice provider, geriatric practice provider, gynecologist, internist, nurse practitioner, obstetrician, pediatrician, physician’s assistant, or personal care provider.

* Note that if you see a non-contracted provider, you will be responsible for the difference between the allowable amount and the provider’s billed charges, in addition to the coinsurance and any applicable copay. The allowable amount for a non-contracted provider is determined by Premera as described in your benefit booklet.

View the Summary of Benefits and Coverage, a glossary, and Supplemental Guide at premera.com/SBC. There is also information about privacy policies, provider organizations, key utilization management procedures, and pharmaceutical management procedures on the site.

General exclusions and limitations Benefit plans typically have exclusions and limitations—what the plans limit or do not cover. The following are general exclusions and limitations for Premera benefit plans.*

What is limited or not covered

Benefits are not provided for treatment, surgery, services, drugs, or supplies for any of the following:

• Any disease, ailment, or condition listed as not covered in the contract

• Caffeine dependence

• Complications of non-covered services

• Conditions arising from acts of war or service in the military

• Conditions arising from the member’s commission of a felony or act of terrorism

• Convenience items (i.e., guest meals and services, television, telephone charges)

• Cosmetic or reconstructive surgery (except as specifically provided) and supplies

• Dental services (except as specifically provided)

• Dietary and food supplements (except medical foods)

• Experimental or investigative services

• Hair loss/cranial prosthesis (wig)

• Infertility treatment (except as specifically provided)

• Institutional care, housing, incarceration, or programs from facilities that are not licensed to provide medical or behavioral health treatment for covered conditions.

• Over-the-counter or non-prescription drugs, except as required by law

• Private duty nursing

• Services in excess of specified benefit maximums and/or allowable charges

• Services payable by other types of insurance such as motor vehicle insurance or liability insurance

• Services received when you are not covered by this program

• Sexual dysfunction

• Vision therapy, eye exercise, and vision surgeries to improve the refractive character of the cornea (L ASIK)

• Vocational counseling, vocational rehabilitation, and recreational therapy

• Voluntary support groups

• Work-related conditions for which you are eligible for benefits from other sources

Prior authorization Certain medical services and prescriptions require approval from the health plan before the member gets them. Contact your Premera representative for more information. More information

A supplemental guide that shares information about privacy policies, provider organization, key utilization management procedures, and pharmaceutical management procedures is available on premera.com.

* For a complete list of the exclusions and limitations, please see the plan contract or visit premera.com.

Contact your Premera Blue Cross representative for more information.