BlueCare Dental and BlueCare Dental 4 Kids

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1 and 4 Kids For more information on available dental plans, please choose one of the options below. If you are looking for coverage for 2016, please click on 2016 below If you want coverage beginning January 1, 2017, please click on 2017 below A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association

2 2016 for Individuals and Families Complete your health care coverage with affordable dental plans from Blue Cross and Blue Shield of Texas. Dental care is a vital part of your overall health. That is why Blue Cross and Blue Shield of Texas (BCBSTX) offers and 4 Kids. Our dental plans provide you with savings on preventive services like checkups, cleanings and basic X-rays, as well as on procedures like fillings, bridges and crowns. BCBSTX offers three plans for both adults and children, designed to fit your needs and your budget. 1A and 4 Kids 1A feature: 100% coverage on most preventive services with in-network dentists Low $50 deductible for in-network services $1,500 maximum; unlimited annual maximum on BlueCare Dental 4 Kids 1A 2A Coverage for most utilized preventive services $75 deductible for many services Savings on dental procedures up to the annual $1000 Maximum for adults; unlimited annual maximum for children 1B and 4 Kids 1B feature: Reduced monthly premium (compared to plans 1A) coverage on most preventive services provided by in-network dentists $75 deductible for in-network services $1,000 maximum; unlimited annual maximum on 4 Kids 1B Get more information at bcbstx.com or call See the chart on the back of this page for more plan details.

3 1 Texas Dental Plans Benefits Payable 1A 4 Kids 1A 1B 2 4 Kids 1B 2A In Network In Network In Network In Network Adult Child Deductible (3x Family) $50 $50 $75 $75 $75 $75 Annual Maximum $1,500 3 N/A $1,000 3 N/A $1,000 N/A Diagnostic Evaluations 100% 4 100% 4 90% 4 4 Preventive 100% 4 100% 4 90% Diagnostic Radiographs 100% 4 100% 4 90% Misc Preventive Services 90% Basic Restorative 70% Non-Surgical Extractions 70% Non-Surgical Periodontal 70% Adjunctive Services Endodontics 70% Please refer to the Outline of Coverage for Oral Surgery schedule of benefits. Surgical Periodontal 5 Major Restorative 5 Prosthodontics 5 Misc Restorative & Prosthodontics Services 5 Orthodontics (up to age 21) N/A ** N/A ** ** Out-of-Pocket Maximum 6 Monthly Premium Rates for 7 Region I 8 Region II 9 Region I 8 Region II 9 Region I 8 Region II 9 Region I 8 Region II 9 Region I 8 Region II 9 4 Adult Child Adult Child Primary Applicant $41.80 $34.28 $38.98 $31.96 $26.33 $21.59 $27.33 $22.41 $ $ Member + Spouse $83.60 $68.56 N/A N/A $52.66 $43.18 N/A N/A N/A N/A $54.08 N/A Member + 1 Child $80.78 $66.24 N/A N/A $53.66 $44.00 N/A N/A N/A N/A $49.45 N/A Family* $ $ N/A N/A $ $ N/A N/A N/A N/A $ N/A Get more information at bcbstx.com or call Or contact an independent Blue Cross and Blue Shield of Texas agent This document does not contain a complete listing of the exclusions limitations and conditions that apply to the benefits shown. For full information refer to the member s certificate of benefits booklet. 2. If choosing 1B for family coverage, please refer to the policy s certificate of benefits booklet. Plan details for dependents under age 21 are not shown above. 3. Annual maximum does not apply to members up to age Deductible waived 5. Waiting period may apply for adults. 6. Out of Pocket Maximum only applies to members up to age Rates subject to change. 8. Region 1 rates apply to members residing in the following counties: Archer, Austin, Bastrop, Brazoria, Caldwell, Chambers, Clay, Collin, Dallas, Delta, Denton, Ellis, Fort Bend, Galveston, Grayson, Harris, Hays, Hunt, Johnson, Kaufman, Liberty, Montgomery, Parker, Rockwall, San Jacinto, Tarrant, Travis, Waller, Wichita, Williamson and Wise. 9. Region 2 rates apply to all members residing in counties outside Region 1. * Includes insured, spouse, and three children for this example. ** 24 month waiting period for pediatric orthodontics A person should not send money to the issuer of the health benefit plan in response to the advertisement; a person cannot obtain coverage under the health benefit plan until the person completes an application for coverage; benefit exclusions and limitations may apply to the health benefit plan. Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association

4 2017 for Individuals and Families Complete your health care coverage with affordable dental plans from Blue Cross and Blue Shield of Texas. Dental care is a vital part of your overall health. That is why Blue Cross and Blue Shield of Texas (BCBSTX), a Division of Health Care Service Corporation, offers and 4 Kids. Our dental plans provide you with savings on preventive services like checkups, cleanings and basic X-rays, as well as on procedures like fillings, bridges and crowns. BCBSTX offers three plans for both adults and children, designed to fit your needs and your budget. 1A and 4 Kids 1A feature: 100% coverage on most preventive services with in-network dentists Low $50 deductible for in-network services $1,500 maximum; unlimited annual maximum on 4 Kids 1A 2A features: Coverage for most utilized preventive services $75 deductible for many services Savings on dental procedures up to the annual $1,000 maximum for adults; unlimited annual maximum for children 1B and 4 Kids 1B feature: Lower monthly premium (compared to 1A plans) 90% coverage on most preventive services provided by in-network dentists $75 deductible for in-network services $1,000 maximum; unlimited annual maximum on 4 Kids 1B Get more information at bcbstx.com or call See the chart on the back for more plan details.

5 1 Dental Plans Benefits Payable 1A 2 4 Kids 1A 1B 2 4 Kids 1B Get more information at bcbstx.com or call Or contact an independent, authorized Blue Cross and Blue Shield of Texas agent. 2A In Network In Network In Network In Network Adult Child Deductible (3x Family) $50 $50 $75 $75 $75 $75 Annual Maximum $1,500 3 N/A $1,000 3 N/A $1,000 N/A Diagnostic Evaluations 100% 4 100% 4 90% Preventive 100% 4 100% 4 90% Diagnostic Radiographs 100% 4 100% 4 90% Miscellaneous Preventive Services 90% Basic Restorative 70% Non-Surgical Extractions 70% Non-Surgical 70% Please refer to Periodontal the Outline of Adjunctive Services 70% Coverage for Endodontics schedule of benefits. Oral Surgery Surgical Periodontal 5 5 Major Restorative 5 5 Prosthodontics 5 5 Miscellaneous Restorative & Prosthodontics Services 5 5 Orthodontics (up to age 21) N/A N/A Out-of-Pocket Maximum 6 Monthly Premium Rates for Region I 8 Region II 9 Region I 8 Region II 9 Region I 8 Region II 9 Region I 8 Region II 9 Region I 8 Region II 9 Adult Child Adult Child Primary Applicant $41.80 $34.28 $34.77 $28.51 $26.33 $21.59 $18.83 $15.44 $32.97 $18.83 $27.04 $15.44 Member + Spouse $83.60 $68.56 N/A N/A $52.66 $43.18 N/A N/A $65.94 N/A $54.08 N/A Member + 1 Child $76.57 $62.79 N/A N/A $45.16 $37.03 N/A N/A $51.80 N/A $42.48 N/A Family* $ $ N/A N/A $ $89.50 N/A N/A $ N/A $ N/A 1. This document does not contain a complete listing of the exclusions, limitations and conditions that apply to the benefits shown. For full information refer to the member s certificate of benefits booklet. All benefits shown represent what the Plan pays. 2. If choosing family coverage, for 1A please refer to 4 Kids 1A for plan details for dependents under 21. If choosing 1B, refer to 4 Kids 1B for plan details for dependents under Annual maximum does not apply to members up to age Deductible is waived. 5. Waiting period may apply for adults. 6. Out-of-Pocket Maximum only applies to members up to age Rates are subject to change. 8. Region 1 rates apply to members residing in the following counties: Archer, Austin, Bastrop, Brazoria, Caldwell, Chambers, Clay, Collin, Dallas, Delta, Denton, Ellis, Fort Bend, Galveston, Grayson, Harris, Hays, Hunt, Johnson, Kaufman, Liberty, Montgomery, Parker, Rockwall, San Jacinto, Tarrant, Travis, Waller, Wichita, Williamson and Wise. 9. Region 2 rates apply to all members residing in counties outside Region 1. * Includes insured, spouse, and three children for this example. Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association