Services and products provided by Horizon Blue Cross Blue Shield of New Jersey and HorizonHealthcare Dental, Inc., independent licensees of the Blue Cross and Blue Shield Association.The Blue Cross® and Blue Shield® names and symbols are registered marks of the Blue Crossand Blue Shield Association. The Horizon® name, symbols and Making Healthcare Work® areregistered marks of Horizon Blue Cross Blue Shield of New Jersey. © 2013 Horizon Blue CrossBlue Shield of New Jersey, Three Penn Plaza East, Newark, New Jersey 07105-2200.

92801 (W0213)

HorizonBlue.com

Horizon Individual PlanCompare the savings over typical charges

Some services that you receive at the preferred programrates:

Eligible Preventive Typical Typical and Basic Services You Pay Charge* Savings

Periodic oral exam $0 $56 $56 Cleaning (adult) $0 $101 $101Amalgam fillings $0 $213 $213(3 surfaces)Sealant per tooth $0 $55 $55Simple extractions $0 $192 $192

In your first year, you'll save 30 percent or more on thesecovered major services. When you stay with the same primary care dentist, your savings for eligible major services increase to 40 percent in the second year and to 50 percent in the third year and thereafter!

YourEligible Discount Typical TypicalMajor Services First Year Charge* Savings

Crown (porcelain) 30% $1,117 $335.10Complete dentureUpper 30% $1,443 $432.90Lower 30% $1,443 $432.90Partial dentureUpper 30% $1,218 $365.40Lower 30% $1,416 $424.80Root canal therapy 30% $1,192 $357.60Periodontics: Scaling and root planing per quadrant 30% $253 $75.90

It costs just $180 per year for adult and $68.40 per year for each dependent child.* Based on the 75th percentile of 2013 Fair Health Relative Value Benchmarks (FHRVB). Typical charges are provided for illustrative purposes only. Actual charges will vary.

32154 (W0513) An Independent Licensee of the Blue Cross and Blue Shield Association

Enroll today in Horizon Individual Dental! Please provide complete information for each family member/individual you wish to enroll in Horizon Individual Dental. You must complete all information for your enrollment form to be processed. Visit HorizonBlue.com/Dental to find a participating dental office and the dental office ID number. Children under age 19 years must be enrolled with at least one parent/guardian. Children ages 19 to 23 years must be full-time students to enroll at the child rate. For questions or help completing this form, call Customer Service at 1-855-648-1400.

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

NJ NJ NJ NJ NJ NJ Your Contact Information Address City State ZIP Code

Day Phone Number E-mail Address

Amount Due Number of Adults Enrolling _______ Number of Children Enrolling _______ Annual Adult Rate: $180.00 Annual Child Rate: $68.40

Total Amount Due $___________________

Select One Payment Option Payment enclosed. Make check or money order payable to: Horizon Healthcare Dental, 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 ________________________________________________________________________________

Card Holder Signature ________________________________________________________________ Date _________________________ Signature Effective date: If the completed application and payment are received by the 15th of the month, the effective date is the 1st of the next month. If received after the 15th, the effective date is the 1st of the month following the next month. Adult Applicant’s Signature _________________________________________________________ Date _________________

HorizonBlue.com/Dental

Horizon BCBSNJ provides administrative claims reimbursement services only and does notassume financial risk or obligation with respect to claims. Services and products provided byHorizon Blue Cross Blue Shield of New Jersey and Horizon Healthcare Dental, Inc., independentlicensees of the Blue Cross and Blue Shield Association. The Blue Cross® and Blue Shield®names and symbols are registered marks of the Blue Cross and Blue Shield Association. TheHorizon® 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. Visa® is a registered mark of VisaInc. MasterCard® is a registered trademark or service mark of MasterCard Worldwide or itssubsidiaries in the United States. 9280 (W0213)

Horizon Individual Dental – affordable, preventive

dental coverage you can count on.

For more information, please visitHorizonBlue.com/Dental or call

1-855-648-1400.

You don’t have to be a group member to qualifyfor participation in Horizon Individual Dental.

This brochure describes the major features and benefits of Horizon IndividualDental from Horizon Healthcare Dental, Inc.

It is not a contract and some limitations may apply.

Please detach and mail the enrollment application to:

Horizon BCBSNJ Dental Programs P.O. Box 1471 Minneapolis, MN

55440-1471

We select dentists with the same care that you would Since our success depends on your relationship withyour primary care dentist, we take great care in choosing participating dentists.

Horizon Individual Dental is designed to give you accessto dental care, so you can improve your dental health.

Take advantage of Horizon Individual Dental. It couldsave you hundreds of dollars in a single year and prevent costly major dental work in the years ahead.

Avoid costly and unexpecteddental bills. Enroll today!Take a few minutes to fill out the attached application and select your primary care dentist atHorizonBlue.com/Dental. Return your completed application and annual premium payment in the enclosedbusiness reply envelope, and we’ll send your policy booklet and identification card.

Guaranteed acceptance with a 30-day “free look”When you enroll in Horizon Individual Dental, you cannot be turned down due to age, occupation, dentalhistory or current dental condition. As long as you make your annual premium payment with a valid creditcard, check or money order, you’ll be accepted.

You get a 30-day “free look” once you’ve enrolled. If for any reason during this 30-day period you decideHorizon Individual Dental is not right for you, we willrefund your premium, less any charges for services utilized during the "free look" period.

Horizon Individual Dental gives you automatic renewal.You will receive a renewal notice before your agreementexpires.

Apply today — and start smiling!

9280 3 fold Indv-Dental_Update_9280 3 fold Indv-Dental 2/13/13 2:23 PM Page 1

A healthy smile is on your horizon Regular, preventive dental care can dramatically reduceyour need for major dental work in the years ahead.That’s why Horizon Individual Dental makes preventivetreatment affordable.

Ideal for individuals who are New Jersey residentsYou don’t have to be a group or association member toenroll in Horizon Individual Dental benefits.

Horizon Individual Dental offers most eligible preventiveand basic dental services with no deductible, copaymentor benefit maximum, and no forms to complete after initial enrollment. After you pay your annual premium and select your primary care dentist, your basic dentalwork costs $0.

Your selected primary care dentist must provide all services.

Should you need major dental work, your participation in Horizon Individual Dental entitles you to tremendoussavings on most eligible dental services.

Use your Horizon Individual Dental benefits as often asyou need. Horizon Individual Dental cannot be canceledduring the agreement term.

Specialty care savings, tooIf you need specialty care, you can still save money. If your primary care dentist recommends specialty care for treatment not covered as a basic or major service under the plan, he or she will refer you to a select group of specialists, which will qualify you for significant savings.

Participating specialists accept reduced fees for Horizon Individual Dental members. Your savings varydepending upon the treatment you require. These savings are available immediately and do not coincide or increase with your time in the plan, as do eligible major services.

!!

!!

Dental Enrollment Form

Enroll today in Horizon Individual Dental! Please provide complete information for each family member/individual you wish to enroll in Horizon Individual Dental. You must complete all information for your enrollment form to be processed. Visit HorizonBlue.com/Dental to find a participating dental office and the dental office ID number. Children under age 19 years must be enrolled with at least one parent/guardian. Children ages 19 to 23 years must be full-time students to enroll at the child rate. For questions or help completing this form, call Customer Service at 1-855-648-1400.

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

NJ NJ NJ NJ NJ NJ Your Contact Information Address City State ZIP Code

Day Phone Number E-mail Address

Amount Due Number of Adults Enrolling _______ Number of Children Enrolling _______ Annual Adult Rate: $180.00 Annual Child Rate: $68.40

Total Amount Due $___________________

Select One Payment Option

Payment enclosed. Make check or money order payable to: Horizon Healthcare Dental, 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 ________________________________________________________________________________

Card Holder Signature ________________________________________________________________ Date _________________________ Signature Effective date: If the completed application and payment are received by the 15th of the month, the effective date is the 1st of the next month. If received after the 15th, the effective date is the 1st of the month following the next month. Adult Applicant’s Signature _________________________________________________________ Date _________________

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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.

CMC0007954 (0516)

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

If you need help understanding this Horizon Blue Cross Blue Shield of New Jersey information,

you have the right to get help in your language at no cost to you. To talk to an interpreter, please

call 1-800-4DENTAL (6825) during normal business hours.

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nida’anishgo oolki[77 bik’ehgo hod77lnih.

ArabicHorizon Blue Cross Blue Shield of New Jersey

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Urdu(

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