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It is not a contract. Additional limitations and ) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 0 222 Tm (exclusions may apply. Payment amounts are based on BCBSM's approved amount, less any applicable deductible and/or copay. For a complete ) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 0 212.8 Tm (description of benefits please see the applicable BCBSM certificates and riders, if your group is underwritten. If your group is self-funded, please ) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 0 203.6 Tm (see any other plan documents your group uses. If there is a discrepancy between this Benefits-at-a-Glance and any applicable plan document, the ) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 0 194.4 Tm (plan document will control. ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 0 176 Tm (Coverage determination:) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 94.24 176 Tm ( Claims are subject to dental necessity verification and availability of dental benefits when they are processed, as well as ) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 0 166.8 Tm (the terms and conditions of the applicable BCBSM certificates and riders. ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 0 148.4 Tm (Dentist information ) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 0 139.2 Tm (With Blue Dental PPO, you can choose any licensed dentist anywhere. 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Tier 1 PPO dentists ) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 0 102.41 Tm (agree to accept our PPO approved amount as full payment for covered services, so you'll pay your applicable coinsurance and deductible amounts. ) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 0 93.21 Tm (To find a Tier 1 PPO dentist near you, log into your member account at ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 253.02 93.21 Tm (bcbsm.com) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 297.47 93.21 Tm ( or call ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 323.26 93.21 Tm (1-888-826-8152. ) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 0 74.81 Tm (If you go to a non-PPO dentist, you can still save money by choosing a Tier 2 participating non-PPO $out-of-network$ dentist. Tier 2 dentists ) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 0 65.61 Tm (participate with us on a "per claim" basis through our Blue Par Select $BPS$ arrangement. They accept our BPS approved amount as full payment ) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 0 56.41 Tm (for covered services, so you'll pay your applicable coinsurance and deductible amounts. To find a Tier 2 participating non-PPO dentist near you, log ) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 0 47.21 Tm (into your member account at ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 103.61 47.21 Tm (bcbsm.com) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 148.06 47.21 Tm (. You should ask your dentist if they participate with BCBSM before every treatment. ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 0 28.81 Tm (Note:) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 20.44 28.81 Tm ( If you go to a nonparticipating dentist, you are responsible for any difference between our approved amount and the dentist's charge. ) Tj ET EMC Q q Q q 1 0 0 1 36 224.28 cm /Artifact <> BDC 0.41961 0.53333 0.83137 RG 0 J 20.7 w -1.45 68.75 m 542.6 68.75 l S 1 w 0.83922 0.84314 0.9098 RG 17.25 w -1.45 49.77 m 220.25 49.77 l S 1 w 17.25 w 220.75 49.77 m 542.6 49.77 l S 1 w 1 1 1 RG 38.27 w -1.45 21.51 m 220.25 21.51 l S 1 w 0.92941 0.95294 0.99608 RG 38.4 w 220.5 21.57 m 542.6 21.57 l S 1 w 0.86275 0.86275 0.86275 RG -1.45 1.5 m 542.6 1.5 l S EMC /Span <>BDC 1 1 1 rg BT /F3 12 Tf 1 0 0 1 2.9 64.78 Tm (Eligibility information ) Tj ET EMC /Span <>BDC 0.2 0.2 0.2 rg BT /F3 9 Tf 1 0 0 1 2.9 46.8 Tm (Member ) Tj ET EMC /Span <>BDC BT /F3 9 Tf 1 0 0 1 224.85 46.8 Tm (Eligibility Criteria ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 2.9 31.41 Tm (Dependents ) Tj ET EMC /Span <>BDC 0.2 0.2 0.2 RG BT /F19 8 Tf 0.5 w 2 Tr 1 0 0 1 223.4 32.73 Tm (x) Tj ET 0.86275 0.86275 0.86275 RG 0.001 w 0 Tr EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 234.2 32.73 Tm (Subscriber's legal spouse ) Tj ET EMC /Span <>BDC 0.2 0.2 0.2 RG BT /F19 8 Tf 0.5 w 2 Tr 1 0 0 1 223.4 22.73 Tm (x) Tj ET 0.86275 0.86275 0.86275 RG 0.001 w 0 Tr EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 234.2 22.73 Tm (Dependent children: related to you by birth, marriage, legal adoption or legal ) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 234.2 13.53 Tm (guardianship; eligible for dental coverage through the end of the calendar year in ) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 234.2 4.33 Tm (which they turn age 26, provided all eligibility requirements are met. ) Tj ET EMC q n 2.9 2 m 546.95 2 l 546.95 1 l 2.9 1 l h W n Q /Artifact <> BDC 2 J 0.5 w [] 0 d 1 1 1 RG 220.5 58.4 m 220.5 2.38 l S 1 w [] 0 d 0.5 w [] 0 d 542.85 79.1 m 542.85 1 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 40.9 m 542.35 40.9 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 2.13 m 542.35 2.13 l S 1 w [] 0 d EMC q n 0 1 m 612 1 l 612 0 l 0 0 l h W n Q Q q Q q 1 0 0 1 36 87.75 cm /Artifact <> BDC 0.41961 0.53333 0.83137 RG 0 J 20.7 w -1.45 112.75 m 542.6 112.75 l S 1 w 0.83922 0.84314 0.9098 RG 17.25 w -1.45 93.78 m 220.25 93.78 l S 1 w 17.25 w 220.75 93.78 m 542.6 93.78 l S 1 w 1 1 1 RG 13.2 w -1.45 78.06 m 220.25 78.06 l S 1 w 0.92941 0.95294 0.99608 RG 13.32 w 220.5 78.12 m 542.6 78.12 l S 1 w 0.86275 0.86275 0.86275 RG 1.25 w -1.45 70.46 m 542.6 70.46 l S 1 w 1 1 1 RG 31.6 w -1.45 53.78 m 220.25 53.78 l S 1 w 0.92941 0.95294 0.99608 RG 31.72 w 220.5 53.85 m 542.6 53.85 l S 1 w 0.86275 0.86275 0.86275 RG 1.25 w -1.45 36.98 m 542.6 36.98 l S 1 w 1 1 1 RG 13.07 w -1.45 29.57 m 220.25 29.57 l S 1 w 0.92941 0.95294 0.99608 RG 13.2 w 220.5 29.63 m 542.6 29.63 l S 1 w 0.86275 0.86275 0.86275 RG 1.25 w -1.45 22.03 m 542.6 22.03 l S 1 w 1 1 1 RG 13.07 w -1.45 14.62 m 220.25 14.62 l S 1 w 0.92941 0.95294 0.99608 RG 13.2 w 220.5 14.69 m 542.6 14.69 l S 1 w 0.86275 0.86275 0.86275 RG 1.25 w -1.45 7.09 m 542.6 7.09 l S 1 w EMC /Span <>BDC 1 1 1 rg BT /F3 12 Tf 1 0 0 1 2.9 108.79 Tm (Member's responsibility $deductible, coinsurance and dollar maximums$ ) Tj ET EMC /Span <>BDC 0.2 0.2 0.2 rg BT /F3 9 Tf 1 0 0 1 2.9 90.81 Tm (Benefits ) Tj ET EMC /Span <>BDC BT /F3 9 Tf 1 0 0 1 224.85 90.81 Tm (Coverage ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 2.9 75.41 Tm (Deductible ) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 223.4 75.54 Tm (None ) Tj ET EMC q n 2.9 71.08 m 546.95 71.08 l 546.95 70.08 l 2.9 70.08 l h W n Q /Span <>BDC 0.2 0.2 0.2 rg BT /F3 8 Tf 1 0 0 1 2.9 60.34 Tm (Coinsurance $percentage of BCBSM's approved amount ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 2.9 51.14 Tm (for covered services$ ) Tj ET EMC /Span <>BDC 0 0 0 RG 0 0 0 rg BT /F34 8 Tf 0.5 w 2 Tr 1 0 0 1 2.9 39.94 Tm (y) Tj ET 0.001 w 0 Tr EMC /Span <>BDC 0.2 0.2 0.2 rg BT /F4 8 Tf 1 0 0 1 13.7 39.94 Tm (Class I services ) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 223.4 60.46 Tm (None $covered at 100%$ ) Tj ET EMC q n 2.9 37.61 m 546.95 37.61 l 546.95 36.61 l 2.9 36.61 l h W n Q /Span <>BDC 0 0 0 RG 0 0 0 rg BT /F34 8 Tf 0.5 w 2 Tr 1 0 0 1 2.9 28.87 Tm (y) Tj ET 0.001 w 0 Tr EMC /Span <>BDC 0.2 0.2 0.2 rg BT /F4 8 Tf 1 0 0 1 13.7 28.87 Tm (Class II services ) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 223.4 26.99 Tm (20% ) Tj ET EMC q n 2.9 22.66 m 546.95 22.66 l 546.95 21.66 l 2.9 21.66 l h W n Q /Span <>BDC 0 0 0 RG 0 0 0 rg BT /F34 8 Tf 0.5 w 2 Tr 1 0 0 1 2.9 13.92 Tm (y) Tj ET 0.001 w 0 Tr EMC /Span <>BDC 0.2 0.2 0.2 rg BT /F4 8 Tf 1 0 0 1 13.7 13.92 Tm (Class III services ) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 223.4 12.04 Tm (50% ) Tj ET EMC q n 2.9 7.71 m 546.95 7.71 l 546.95 6.71 l 2.9 6.71 l h W n Q /Artifact <> BDC 2 J 0.5 w [] 0 d 1 1 1 RG 220.5 102.4 m 220.5 71.46 l S 1 w [] 0 d 0.5 w [] 0 d 220.5 69.58 m 220.5 37.98 l S 1 w [] 0 d 0.5 w [] 0 d 220.5 36.11 m 220.5 23.03 l S 1 w [] 0 d 0.5 w [] 0 d 220.5 21.16 m 220.5 8.09 l S 1 w [] 0 d 0.5 w [] 0 d 542.85 123.1 m 542.85 6.46 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 84.9 m 542.35 84.9 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 71.21 m 542.35 71.21 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 69.83 m 220.5 69.83 l S 1 w [] 0 d 0 J 0.25 w [1 1] 0 d 0.86275 0.86275 0.86275 RG 220.75 69.83 m 542.6 69.83 l S 1 w [] 0 d 2 J 0.5 w [] 0 d 1 1 1 RG -1.2 37.73 m 542.35 37.73 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 36.36 m 220.5 36.36 l S 1 w [] 0 d 0 J 0.25 w [1 1] 0 d 0.86275 0.86275 0.86275 RG 220.75 36.36 m 542.6 36.36 l S 1 w [] 0 d 2 J 0.5 w [] 0 d 1 1 1 RG -1.2 22.78 m 542.35 22.78 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 21.41 m 220.5 21.41 l S 1 w [] 0 d 0 J 0.25 w [1 1] 0 d 0.86275 0.86275 0.86275 RG 220.75 21.41 m 542.6 21.41 l S 1 w [] 0 d 2 J 0.5 w [] 0 d 1 1 1 RG -1.2 7.84 m 542.35 7.84 l S 1 w [] 0 d EMC Q q Q Q endstream endobj 37 0 obj <>>>>> endobj 38 0 obj <> endobj 40 0 obj <> endobj 41 0 obj <> endobj 42 0 obj <> endobj 43 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-1.45 63.8 m 220.25 63.8 l S 1 w 17.25 w 220.75 63.8 m 542.6 63.8 l S 1 w 1 1 1 RG 13.07 w -1.45 48.13 m 220.25 48.13 l S 1 w 0.92941 0.95294 0.99608 RG 13.2 w 220.5 48.2 m 542.6 48.2 l S 1 w 0.86275 0.86275 0.86275 RG 1.25 w -1.45 40.6 m 542.6 40.6 l S 1 w 1 1 1 RG 22.4 w -1.45 28.52 m 220.25 28.52 l S 1 w 0.92941 0.95294 0.99608 RG 22.52 w 220.5 28.59 m 542.6 28.59 l S 1 w 0.86275 0.86275 0.86275 RG 1.25 w -1.45 16.32 m 542.6 16.32 l S 1 w 1 1 1 RG 13.07 w -1.45 8.91 m 220.25 8.91 l S 1 w 0.92941 0.95294 0.99608 RG 13.2 w 220.5 8.98 m 542.6 8.98 l S 1 w 0.86275 0.86275 0.86275 RG -1.45 1.5 m 542.6 1.5 l S EMC /Artifact <> BDC 0.2 0.2 0.2 rg BT /F3 9 Tf 1 0 0 1 2.9 60.82 Tm (Benefits ) Tj ET BT /F3 9 Tf 1 0 0 1 224.85 60.82 Tm (Coverage ) Tj ET EMC /Span <>BDC 0 0 0 RG 0 0 0 rg BT /F34 8 Tf 0.5 w 2 Tr 1 0 0 1 2.9 47.43 Tm (y) Tj ET 0.86275 0.86275 0.86275 RG 0.001 w 0 Tr EMC /Span <>BDC 0.2 0.2 0.2 rg BT /F4 8 Tf 1 0 0 1 13.7 47.43 Tm (Class IV services ) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 223.4 45.56 Tm (50% ) Tj ET EMC q n 2.9 41.22 m 546.95 41.22 l 546.95 40.22 l 2.9 40.22 l h W n Q /Span <>BDC 0.2 0.2 0.2 rg BT /F3 8 Tf 1 0 0 1 2.9 30.48 Tm (Dollar maximums ) Tj ET EMC /Span <>BDC 0 0 0 RG 0 0 0 rg BT /F34 8 Tf 0.5 w 2 Tr 1 0 0 1 2.9 19.28 Tm (y) Tj ET 0.001 w 0 Tr EMC /Span <>BDC 0.2 0.2 0.2 rg BT /F4 8 Tf 1 0 0 1 13.7 19.28 Tm (Annual maximum for Class I, II and III services ) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 223.4 30.61 Tm ($1,000 per member ) Tj ET EMC q n 2.9 16.95 m 546.95 16.95 l 546.95 15.95 l 2.9 15.95 l h W n Q /Span <>BDC 0 0 0 RG 0 0 0 rg BT /F34 8 Tf 0.5 w 2 Tr 1 0 0 1 2.9 8.21 Tm (y) Tj ET 0.001 w 0 Tr EMC /Span <>BDC 0.2 0.2 0.2 rg BT /F4 8 Tf 1 0 0 1 13.7 8.21 Tm (Lifetime maximum for Class IV services ) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 223.4 6.33 Tm ($1,500 per member ) Tj ET EMC q n 2.9 2 m 546.95 2 l 546.95 1 l 2.9 1 l h W n Q /Artifact <> BDC 2 J 0.5 w [] 0 d 1 1 1 RG 220.5 72.42 m 220.5 41.6 l S 1 w [] 0 d 0.5 w [] 0 d 220.5 39.72 m 220.5 17.32 l S 1 w [] 0 d 0.5 w [] 0 d 220.5 15.45 m 220.5 2.38 l S 1 w [] 0 d 0.5 w [] 0 d 542.85 72.42 m 542.85 1 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 54.92 m 542.35 54.92 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 41.35 m 542.35 41.35 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 39.97 m 220.5 39.97 l S 1 w [] 0 d 0 J 0.25 w [1 1] 0 d 0.86275 0.86275 0.86275 RG 220.75 39.97 m 542.6 39.97 l S 1 w [] 0 d 2 J 0.5 w [] 0 d 1 1 1 RG -1.2 17.07 m 542.35 17.07 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 15.7 m 220.5 15.7 l S 1 w [] 0 d 0 J 0.25 w [1 1] 0 d 0.86275 0.86275 0.86275 RG 220.75 15.7 m 542.6 15.7 l S 1 w [] 0 d 2 J 0.5 w [] 0 d 1 1 1 RG -1.2 2.13 m 542.35 2.13 l S 1 w [] 0 d EMC q n 0 1 m 612 1 l 612 0 l 0 0 l h W n Q Q q Q q 1 0 0 1 36 421.99 cm /Artifact <> BDC 0.41961 0.53333 0.83137 RG 0 J 20.7 w -1.45 237.11 m 542.6 237.11 l S 1 w 0.83922 0.84314 0.9098 RG 17.25 w -1.45 218.14 m 220.25 218.14 l S 1 w 17.25 w 220.75 218.14 m 542.6 218.14 l S 1 w 1 1 1 RG 22.27 w -1.45 197.88 m 220.25 197.88 l S 1 w 0.92941 0.95294 0.99608 RG 22.4 w 220.5 197.94 m 542.6 197.94 l S 1 w 0.86275 0.86275 0.86275 RG 1.25 w -1.45 185.74 m 542.6 185.74 l S 1 w 1 1 1 RG 22.27 w -1.45 173.73 m 220.25 173.73 l S 1 w 0.92941 0.95294 0.99608 RG 22.4 w 220.5 173.79 m 542.6 173.79 l S 1 w 0.86275 0.86275 0.86275 RG 1.25 w -1.45 161.59 m 542.6 161.59 l S 1 w 1 1 1 RG 22.27 w -1.45 149.58 m 220.25 149.58 l S 1 w 0.92941 0.95294 0.99608 RG 22.4 w 220.5 149.64 m 542.6 149.64 l S 1 w 0.86275 0.86275 0.86275 RG 1.25 w -1.45 137.44 m 542.6 137.44 l S 1 w 1 1 1 RG 22.27 w -1.45 125.43 m 220.25 125.43 l S 1 w 0.92941 0.95294 0.99608 RG 22.4 w 220.5 125.49 m 542.6 125.49 l S 1 w 0.86275 0.86275 0.86275 RG 1.25 w -1.45 113.29 m 542.6 113.29 l S 1 w 1 1 1 RG 31.47 w -1.45 96.68 m 220.25 96.68 l S 1 w 0.92941 0.95294 0.99608 RG 31.6 w 220.5 96.74 m 542.6 96.74 l S 1 w 0.86275 0.86275 0.86275 RG 1.25 w -1.45 79.95 m 542.6 79.95 l S 1 w 1 1 1 RG 13.2 w -1.45 72.47 m 220.25 72.47 l S 1 w 0.92941 0.95294 0.99608 RG 13.32 w 220.5 72.53 m 542.6 72.53 l S 1 w 0.86275 0.86275 0.86275 RG 1.25 w -1.45 64.87 m 542.6 64.87 l S 1 w 1 1 1 RG 22.27 w -1.45 52.86 m 220.25 52.86 l S 1 w 0.92941 0.95294 0.99608 RG 22.4 w 220.5 52.92 m 542.6 52.92 l S 1 w 0.86275 0.86275 0.86275 RG 1.25 w -1.45 40.72 m 542.6 40.72 l S 1 w 1 1 1 RG 22.4 w -1.45 28.65 m 220.25 28.65 l S 1 w 0.92941 0.95294 0.99608 RG 22.52 w 220.5 28.71 m 542.6 28.71 l S 1 w 0.86275 0.86275 0.86275 RG 1.25 w -1.45 16.45 m 542.6 16.45 l S 1 w 1 1 1 RG 13.2 w -1.45 8.98 m 220.25 8.98 l S 1 w 0.92941 0.95294 0.99608 RG 13.32 w 220.5 9.04 m 542.6 9.04 l S 1 w 0.86275 0.86275 0.86275 RG -1.45 1.5 m 542.6 1.5 l S EMC /Span <>BDC 1 1 1 rg BT /F3 12 Tf 1 0 0 1 2.9 233.15 Tm (Class I services ) Tj ET EMC /Span <>BDC 0.2 0.2 0.2 rg BT /F3 9 Tf 1 0 0 1 2.9 215.16 Tm (Benefits ) Tj ET EMC /Span <>BDC BT /F3 9 Tf 1 0 0 1 224.85 215.16 Tm (Coverage ) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 2.9 199.77 Tm (Oral exams ) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 223.4 199.9 Tm (100% of approved amount ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 223.4 190.7 Tm (Note:) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 243.84 190.7 Tm ( Twice per calendar year ) Tj ET EMC q n 2.9 186.36 m 546.95 186.36 l 546.95 185.36 l 2.9 185.36 l h W n Q /Span <>BDC 0.2 0.2 0.2 rg BT /F4 8 Tf 1 0 0 1 2.9 175.62 Tm (A set $up to 4 films$ of bitewing x-rays ) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 223.4 175.75 Tm (100% of approved amount ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 223.4 166.55 Tm (Note:) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 243.84 166.55 Tm ( Twice per calendar year ) Tj ET EMC q n 2.9 162.21 m 546.95 162.21 l 546.95 161.21 l 2.9 161.21 l h W n Q /Span <>BDC 0.2 0.2 0.2 rg BT /F4 8 Tf 1 0 0 1 2.9 151.47 Tm (Panoramic or full-mouth x-rays ) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 223.4 151.6 Tm (100% of approved amount ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 223.4 142.4 Tm (Note:) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 243.84 142.4 Tm ( Once every 60 months ) Tj ET EMC q n 2.9 138.07 m 546.95 138.07 l 546.95 137.07 l 2.9 137.07 l h W n Q /Span <>BDC 0.2 0.2 0.2 rg BT /F4 8 Tf 1 0 0 1 2.9 127.33 Tm (Prophylaxis $cleaning$ ) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 223.4 127.45 Tm (100% of approved amount ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 223.4 118.25 Tm (Note:) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 243.84 118.25 Tm ( Twice per calendar year ) Tj ET EMC q n 2.9 113.92 m 546.95 113.92 l 546.95 112.92 l 2.9 112.92 l h W n Q /Span <>BDC 0.2 0.2 0.2 rg BT /F4 8 Tf 1 0 0 1 2.9 103.18 Tm (Sealants - for members age 19 and younger ) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 223.4 103.3 Tm (100% of approved amount ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 223.4 94.1 Tm (Note:) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 243.84 94.1 Tm ( Once per tooth in any 36 consecutive months when applied to the first and second ) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 223.4 84.9 Tm (permanent molars. This period begins on the date of the member's first treatment. ) Tj ET EMC q n 2.9 80.57 m 546.95 80.57 l 546.95 79.57 l 2.9 79.57 l h W n Q /Span <>BDC 0.2 0.2 0.2 rg BT /F4 8 Tf 1 0 0 1 2.9 69.83 Tm (Emergency palliative treatment ) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 223.4 69.95 Tm (100% of approved amount ) Tj ET EMC q n 2.9 65.5 m 546.95 65.5 l 546.95 64.5 l 2.9 64.5 l h W n Q /Span <>BDC 0.2 0.2 0.2 rg BT /F4 8 Tf 1 0 0 1 2.9 54.75 Tm (Fluoride treatments ) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 223.4 54.88 Tm (100% of approved amount ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 223.4 45.68 Tm (Note:) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 243.84 45.68 Tm ( Two per calendar year ) Tj ET EMC q n 2.9 41.35 m 546.95 41.35 l 546.95 40.35 l 2.9 40.35 l h W n Q /Span <>BDC 0.2 0.2 0.2 rg BT /F4 8 Tf 1 0 0 1 2.9 30.61 Tm (Space maintainers - missing posterior $back$ primary teeth - ) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 2.9 21.41 Tm (for members 18 and younger ) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 223.4 30.73 Tm (100% of approved amount ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 223.4 21.53 Tm (Note:) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 243.84 21.53 Tm ( Once per quadrant per lifetime ) Tj ET EMC q n 2.9 17.08 m 546.95 17.08 l 546.95 16.08 l 2.9 16.08 l h W n Q /Span <>BDC 0.2 0.2 0.2 rg BT /F4 8 Tf 1 0 0 1 2.9 6.33 Tm (Periodontic maintenance ) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 223.4 6.46 Tm (100% of approved amount ) Tj ET EMC q n 2.9 2 m 546.95 2 l 546.95 1 l 2.9 1 l h W n Q /Artifact <> BDC 2 J 0.5 w [] 0 d 1 1 1 RG 220.5 226.76 m 220.5 186.74 l S 1 w [] 0 d 0.5 w [] 0 d 220.5 184.86 m 220.5 162.59 l S 1 w [] 0 d 0.5 w [] 0 d 220.5 160.71 m 220.5 138.44 l S 1 w [] 0 d 0.5 w [] 0 d 220.5 136.57 m 220.5 114.29 l S 1 w [] 0 d 0.5 w [] 0 d 220.5 112.42 m 220.5 80.94 l S 1 w [] 0 d 0.5 w [] 0 d 220.5 79.07 m 220.5 65.87 l S 1 w [] 0 d 0.5 w [] 0 d 220.5 63.99 m 220.5 41.72 l S 1 w [] 0 d 0.5 w [] 0 d 220.5 39.85 m 220.5 17.45 l S 1 w [] 0 d 0.5 w [] 0 d 220.5 15.57 m 220.5 2.38 l S 1 w [] 0 d 0.5 w [] 0 d 542.85 247.46 m 542.85 1 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 209.26 m 542.35 209.26 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 186.49 m 542.35 186.49 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 185.11 m 220.5 185.11 l S 1 w [] 0 d 0 J 0.25 w [1 1] 0 d 0.86275 0.86275 0.86275 RG 220.75 185.11 m 542.6 185.11 l S 1 w [] 0 d 2 J 0.5 w [] 0 d 1 1 1 RG -1.2 162.34 m 542.35 162.34 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 160.96 m 220.5 160.96 l S 1 w [] 0 d 0 J 0.25 w [1 1] 0 d 0.86275 0.86275 0.86275 RG 220.75 160.96 m 542.6 160.96 l S 1 w [] 0 d 2 J 0.5 w [] 0 d 1 1 1 RG -1.2 138.19 m 542.35 138.19 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 136.82 m 220.5 136.82 l S 1 w [] 0 d 0 J 0.25 w [1 1] 0 d 0.86275 0.86275 0.86275 RG 220.75 136.82 m 542.6 136.82 l S 1 w [] 0 d 2 J 0.5 w [] 0 d 1 1 1 RG -1.2 114.04 m 542.35 114.04 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 112.67 m 220.5 112.67 l S 1 w [] 0 d 0 J 0.25 w [1 1] 0 d 0.86275 0.86275 0.86275 RG 220.75 112.67 m 542.6 112.67 l S 1 w [] 0 d 2 J 0.5 w [] 0 d 1 1 1 RG -1.2 80.69 m 542.35 80.69 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 79.32 m 220.5 79.32 l S 1 w [] 0 d 0 J 0.25 w [1 1] 0 d 0.86275 0.86275 0.86275 RG 220.75 79.32 m 542.6 79.32 l S 1 w [] 0 d 2 J 0.5 w [] 0 d 1 1 1 RG -1.2 65.62 m 542.35 65.62 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 64.25 m 220.5 64.25 l S 1 w [] 0 d 0 J 0.25 w [1 1] 0 d 0.86275 0.86275 0.86275 RG 220.75 64.25 m 542.6 64.25 l S 1 w [] 0 d 2 J 0.5 w [] 0 d 1 1 1 RG -1.2 41.47 m 542.35 41.47 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 40.1 m 220.5 40.1 l S 1 w [] 0 d 0 J 0.25 w [1 1] 0 d 0.86275 0.86275 0.86275 RG 220.75 40.1 m 542.6 40.1 l S 1 w [] 0 d 2 J 0.5 w [] 0 d 1 1 1 RG -1.2 17.2 m 542.35 17.2 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 15.82 m 220.5 15.82 l S 1 w [] 0 d 0 J 0.25 w [1 1] 0 d 0.86275 0.86275 0.86275 RG 220.75 15.82 m 542.6 15.82 l S 1 w [] 0 d 2 J 0.5 w [] 0 d 1 1 1 RG -1.2 2.13 m 542.35 2.13 l S 1 w [] 0 d EMC q n 0 1 m 612 1 l 612 0 l 0 0 l h W n Q Q q Q q 1 0 0 1 36 87.75 cm /Artifact <> BDC 0.41961 0.53333 0.83137 RG 0 J 20.7 w -1.45 310.47 m 542.6 310.47 l S 1 w 0.83922 0.84314 0.9098 RG 17.25 w -1.45 291.49 m 220.25 291.49 l S 1 w 17.25 w 220.75 291.49 m 542.6 291.49 l S 1 w 1 1 1 RG 22.27 w -1.45 271.23 m 220.25 271.23 l S 1 w 0.92941 0.95294 0.99608 RG 22.4 w 220.5 271.3 m 542.6 271.3 l S 1 w 0.86275 0.86275 0.86275 RG 1.25 w -1.45 259.1 m 542.6 259.1 l S 1 w 1 1 1 RG 22.27 w -1.45 247.09 m 220.25 247.09 l S 1 w 0.92941 0.95294 0.99608 RG 22.4 w 220.5 247.15 m 542.6 247.15 l S 1 w 0.86275 0.86275 0.86275 RG 1.25 w -1.45 234.95 m 542.6 234.95 l S 1 w 1 1 1 RG 22.4 w -1.45 222.87 m 220.25 222.87 l S 1 w 0.92941 0.95294 0.99608 RG 22.52 w 220.5 222.94 m 542.6 222.94 l S 1 w 0.86275 0.86275 0.86275 RG 1.25 w -1.45 210.68 m 542.6 210.68 l S 1 w 1 1 1 RG 13.2 w -1.45 203.2 m 220.25 203.2 l S 1 w 0.92941 0.95294 0.99608 RG 13.32 w 220.5 203.26 m 542.6 203.26 l S 1 w 0.86275 0.86275 0.86275 RG 1.25 w -1.45 195.6 m 542.6 195.6 l S 1 w 1 1 1 RG 31.47 w -1.45 178.99 m 220.25 178.99 l S 1 w 0.92941 0.95294 0.99608 RG 31.6 w 220.5 179.05 m 542.6 179.05 l S 1 w 0.86275 0.86275 0.86275 RG 1.25 w -1.45 162.25 m 542.6 162.25 l S 1 w 1 1 1 RG 22.27 w -1.45 150.24 m 220.25 150.24 l S 1 w 0.92941 0.95294 0.99608 RG 22.4 w 220.5 150.3 m 542.6 150.3 l S 1 w 0.86275 0.86275 0.86275 RG 1.25 w -1.45 138.1 m 542.6 138.1 l S 1 w 1 1 1 RG 31.47 w -1.45 121.49 m 220.25 121.49 l S 1 w 0.92941 0.95294 0.99608 RG 31.6 w 220.5 121.56 m 542.6 121.56 l S 1 w 0.86275 0.86275 0.86275 RG 1.25 w -1.45 104.76 m 542.6 104.76 l S 1 w 1 1 1 RG 22.27 w -1.45 92.75 m 220.25 92.75 l S 1 w 0.92941 0.95294 0.99608 RG 22.4 w 220.5 92.81 m 542.6 92.81 l S 1 w 0.86275 0.86275 0.86275 RG 1.25 w -1.45 80.61 m 542.6 80.61 l S 1 w 1 1 1 RG 22.27 w -1.45 68.6 m 220.25 68.6 l S 1 w 0.92941 0.95294 0.99608 RG 22.4 w 220.5 68.66 m 542.6 68.66 l S 1 w 0.86275 0.86275 0.86275 RG 1.25 w -1.45 56.46 m 542.6 56.46 l S 1 w 1 1 1 RG 22.27 w -1.45 44.45 m 220.25 44.45 l S 1 w 0.92941 0.95294 0.99608 RG 22.4 w 220.5 44.51 m 542.6 44.51 l S 1 w 0.86275 0.86275 0.86275 RG 1.25 w -1.45 32.31 m 542.6 32.31 l S 1 w 1 1 1 RG 22.27 w -1.45 20.3 m 220.25 20.3 l S 1 w 0.92941 0.95294 0.99608 RG 22.4 w 220.5 20.36 m 542.6 20.36 l S 1 w 0.86275 0.86275 0.86275 RG 1.25 w -1.45 8.16 m 542.6 8.16 l S 1 w EMC /Span <>BDC 1 1 1 rg BT /F3 12 Tf 1 0 0 1 2.9 306.51 Tm (Class II services ) Tj ET EMC /Span <>BDC 0.2 0.2 0.2 rg BT /F3 9 Tf 1 0 0 1 2.9 288.52 Tm (Benefits ) Tj ET EMC /Span <>BDC BT /F3 9 Tf 1 0 0 1 224.85 288.52 Tm (Coverage ) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 2.9 273.13 Tm (Fillings - permanent $adult$ teeth ) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 223.4 273.25 Tm (80% of approved amount ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 223.4 264.05 Tm (Note:) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 243.84 264.05 Tm ( Replacement fillings covered after 24 months or more after initial filling ) Tj ET EMC q n 2.9 259.72 m 546.95 259.72 l 546.95 258.72 l 2.9 258.72 l h W n Q /Span <>BDC 0.2 0.2 0.2 rg BT /F4 8 Tf 1 0 0 1 2.9 248.98 Tm (Fillings - primary $child$ teeth ) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 223.4 249.1 Tm (80% of approved amount ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 223.4 239.91 Tm (Note:) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 243.84 239.91 Tm ( Replacement fillings covered after 12 months or more after initial filling ) Tj ET EMC q n 2.9 235.57 m 546.95 235.57 l 546.95 234.57 l 2.9 234.57 l h W n Q /Span <>BDC 0.2 0.2 0.2 rg BT /F4 8 Tf 1 0 0 1 2.9 224.83 Tm (Recementation of crowns, veneers, inlays, onlays and ) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 2.9 215.63 Tm (bridges ) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 223.4 224.96 Tm (80% of approved amount ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 223.4 215.76 Tm (Note:) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 243.84 215.76 Tm ( Three times per tooth per calendar year after six months from original restoration ) Tj ET EMC q n 2.9 211.3 m 546.95 211.3 l 546.95 210.3 l 2.9 210.3 l h W n Q /Span <>BDC 0.2 0.2 0.2 rg BT /F4 8 Tf 1 0 0 1 2.9 200.56 Tm (Oral surgery ) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 223.4 200.68 Tm (80% of approved amount ) Tj ET EMC q n 2.9 196.23 m 546.95 196.23 l 546.95 195.23 l 2.9 195.23 l h W n Q /Span <>BDC 0.2 0.2 0.2 rg BT /F4 8 Tf 1 0 0 1 2.9 185.48 Tm (Root canal treatment ) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 223.4 185.61 Tm (80% of approved amount ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 223.4 176.41 Tm (Note:) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 243.84 176.41 Tm ( Once per tooth per lifetime; retreatment of previous root canal therapy once per ) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 223.4 167.21 Tm (tooth per lifetime. ) Tj ET EMC q n 2.9 162.88 m 546.95 162.88 l 546.95 161.88 l 2.9 161.88 l h W n Q /Span <>BDC 0.2 0.2 0.2 rg BT /F4 8 Tf 1 0 0 1 2.9 152.14 Tm (Scaling and root planing ) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 223.4 152.26 Tm (80% of approved amount ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 223.4 143.06 Tm (Note:) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 243.84 143.06 Tm ( Once every 24 months per quadrant ) Tj ET EMC q n 2.9 138.73 m 546.95 138.73 l 546.95 137.73 l 2.9 137.73 l h W n Q /Span <>BDC 0.2 0.2 0.2 rg BT /F4 8 Tf 1 0 0 1 2.9 127.99 Tm (Limited occlusal adjustments ) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 223.4 128.11 Tm (80% of approved amount ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 223.4 118.91 Tm (Note:) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 243.84 118.91 Tm ( ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 246.06 118.91 Tm (Limited) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 274.51 118.91 Tm ( occlusal adjustments covered up to five times in any 60 consecutive ) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 223.4 109.71 Tm (months ) Tj ET EMC q n 2.9 105.38 m 546.95 105.38 l 546.95 104.38 l 2.9 104.38 l h W n Q /Span <>BDC 0.2 0.2 0.2 rg BT /F4 8 Tf 1 0 0 1 2.9 94.64 Tm (Occlusal biteguards ) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 223.4 94.77 Tm (80% of approved amount ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 223.4 85.57 Tm (Note:) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 243.84 85.57 Tm ( Once every 12 months ) Tj ET EMC q n 2.9 81.23 m 546.95 81.23 l 546.95 80.23 l 2.9 80.23 l h W n Q /Span <>BDC 0.2 0.2 0.2 rg BT /F4 8 Tf 1 0 0 1 2.9 70.49 Tm (General anesthesia or IV sedation ) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 223.4 70.62 Tm (80% of approved amount ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 223.4 61.42 Tm (Note:) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 243.84 61.42 Tm ( When medically necessary and performed with oral surgery ) Tj ET EMC q n 2.9 57.08 m 546.95 57.08 l 546.95 56.08 l 2.9 56.08 l h W n Q /Span <>BDC 0.2 0.2 0.2 rg BT /F4 8 Tf 1 0 0 1 2.9 46.34 Tm (Repairs and adjustments of a partial or complete denture ) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 223.4 46.47 Tm (80% of approved amount ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 223.4 37.27 Tm (Note:) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 243.84 37.27 Tm ( Six months or more after denture is delivered ) Tj ET EMC q n 2.9 32.94 m 546.95 32.94 l 546.95 31.94 l 2.9 31.94 l h W n Q /Span <>BDC 0.2 0.2 0.2 rg BT /F4 8 Tf 1 0 0 1 2.9 22.19 Tm (Relining or rebasing of a partial or complete denture ) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 223.4 22.32 Tm (80% of approved amount ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 223.4 13.12 Tm (Note:) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 243.84 13.12 Tm ( Once per arch in any 36 consecutive months ) Tj ET EMC q n 2.9 8.79 m 546.95 8.79 l 546.95 7.79 l 2.9 7.79 l h W n Q /Artifact <> BDC 2 J 0.5 w [] 0 d 1 1 1 RG 220.5 300.12 m 220.5 260.1 l S 1 w [] 0 d 0.5 w [] 0 d 220.5 258.22 m 220.5 235.95 l S 1 w [] 0 d 0.5 w [] 0 d 220.5 234.07 m 220.5 211.67 l S 1 w [] 0 d 0.5 w [] 0 d 220.5 209.8 m 220.5 196.6 l S 1 w [] 0 d 0.5 w [] 0 d 220.5 194.73 m 220.5 163.25 l S 1 w [] 0 d 0.5 w [] 0 d 220.5 161.38 m 220.5 139.1 l S 1 w [] 0 d 0.5 w [] 0 d 220.5 137.23 m 220.5 105.76 l S 1 w [] 0 d 0.5 w [] 0 d 220.5 103.88 m 220.5 81.61 l S 1 w [] 0 d 0.5 w [] 0 d 220.5 79.73 m 220.5 57.46 l S 1 w [] 0 d 0.5 w [] 0 d 220.5 55.58 m 220.5 33.31 l S 1 w [] 0 d 0.5 w [] 0 d 220.5 31.44 m 220.5 9.16 l S 1 w [] 0 d 0.5 w [] 0 d 542.85 320.82 m 542.85 7.54 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 282.62 m 542.35 282.62 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 259.85 m 542.35 259.85 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 258.47 m 220.5 258.47 l S 1 w [] 0 d 0 J 0.25 w [1 1] 0 d 0.86275 0.86275 0.86275 RG 220.75 258.47 m 542.6 258.47 l S 1 w [] 0 d 2 J 0.5 w [] 0 d 1 1 1 RG -1.2 235.7 m 542.35 235.7 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 234.32 m 220.5 234.32 l S 1 w [] 0 d 0 J 0.25 w [1 1] 0 d 0.86275 0.86275 0.86275 RG 220.75 234.32 m 542.6 234.32 l S 1 w [] 0 d 2 J 0.5 w [] 0 d 1 1 1 RG -1.2 211.43 m 542.35 211.43 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 210.05 m 220.5 210.05 l S 1 w [] 0 d 0 J 0.25 w [1 1] 0 d 0.86275 0.86275 0.86275 RG 220.75 210.05 m 542.6 210.05 l S 1 w [] 0 d 2 J 0.5 w [] 0 d 1 1 1 RG -1.2 196.35 m 542.35 196.35 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 194.98 m 220.5 194.98 l S 1 w [] 0 d 0 J 0.25 w [1 1] 0 d 0.86275 0.86275 0.86275 RG 220.75 194.98 m 542.6 194.98 l S 1 w [] 0 d 2 J 0.5 w [] 0 d 1 1 1 RG -1.2 163 m 542.35 163 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 161.63 m 220.5 161.63 l S 1 w [] 0 d 0 J 0.25 w [1 1] 0 d 0.86275 0.86275 0.86275 RG 220.75 161.63 m 542.6 161.63 l S 1 w [] 0 d 2 J 0.5 w [] 0 d 1 1 1 RG -1.2 138.85 m 542.35 138.85 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 137.48 m 220.5 137.48 l S 1 w [] 0 d 0 J 0.25 w [1 1] 0 d 0.86275 0.86275 0.86275 RG 220.75 137.48 m 542.6 137.48 l S 1 w [] 0 d 2 J 0.5 w [] 0 d 1 1 1 RG -1.2 105.51 m 542.35 105.51 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 104.13 m 220.5 104.13 l S 1 w [] 0 d 0 J 0.25 w [1 1] 0 d 0.86275 0.86275 0.86275 RG 220.75 104.13 m 542.6 104.13 l S 1 w [] 0 d 2 J 0.5 w [] 0 d 1 1 1 RG -1.2 81.36 m 542.35 81.36 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 79.98 m 220.5 79.98 l S 1 w [] 0 d 0 J 0.25 w [1 1] 0 d 0.86275 0.86275 0.86275 RG 220.75 79.98 m 542.6 79.98 l S 1 w [] 0 d 2 J 0.5 w [] 0 d 1 1 1 RG -1.2 57.21 m 542.35 57.21 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 55.83 m 220.5 55.83 l S 1 w [] 0 d 0 J 0.25 w [1 1] 0 d 0.86275 0.86275 0.86275 RG 220.75 55.83 m 542.6 55.83 l S 1 w [] 0 d 2 J 0.5 w [] 0 d 1 1 1 RG -1.2 33.06 m 542.35 33.06 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 31.69 m 220.5 31.69 l S 1 w [] 0 d 0 J 0.25 w [1 1] 0 d 0.86275 0.86275 0.86275 RG 220.75 31.69 m 542.6 31.69 l S 1 w [] 0 d 2 J 0.5 w [] 0 d 1 1 1 RG -1.2 8.91 m 542.35 8.91 l S 1 w [] 0 d EMC Q q Q Q endstream endobj 104 0 obj <>>>>> endobj 105 0 obj <> endobj 107 0 obj <> endobj 108 0 obj <> endobj 109 0 obj <> endobj 110 0 obj <> endobj 111 0 obj <> endobj 112 0 obj <> endobj 113 0 obj <> endobj 114 0 obj <> endobj 115 0 obj <> endobj 116 0 obj <> endobj 117 0 obj <> endobj 118 0 obj <> endobj 119 0 obj <> endobj 120 0 obj <> endobj 121 0 obj <> endobj 122 0 obj <> endobj 123 0 obj <> endobj 124 0 obj <> endobj 125 0 obj <> endobj 126 0 obj <> endobj 127 0 obj <> endobj 128 0 obj <> endobj 129 0 obj <> endobj 130 0 obj <> endobj 131 0 obj <> endobj 133 0 obj <> endobj 134 0 obj [ 104 0 R /XYZ 38.9 696.03 0] endobj 135 0 obj [ 104 0 R /XYZ 38.9 696.03 0] endobj 136 0 obj <> endobj 138 0 obj <> endobj 139 0 obj <> endobj 140 0 obj <> endobj 141 0 obj <> endobj 142 0 obj <> endobj 143 0 obj <> endobj 144 0 obj <> endobj 145 0 obj <> endobj 146 0 obj <> endobj 147 0 obj <> endobj 148 0 obj [ 104 0 R /XYZ 38.9 537.61 0] endobj 149 0 obj [ 104 0 R /XYZ 38.9 537.61 0] endobj 151 0 obj <>stream q 0 0 612 792 re W n /Artifact <> BDC q 1 0 0 1 36 755.3 cm q n 0 0.7 m 612 0.7 l 612 0 l 0 0 l h W n Q Q q Q EMC /Artifact <> BDC q 1 0 0 1 36 36 cm 0 0 0 rg BT /F3 7 Tf 1 0 0 1 143.01 45.41 Tm (ADM PLANYR JAN;BLUE DENTAL;DO-PPO;ESS VIS;EVC $7.50;EVFL;PK616 ) Tj ET BT /F4 7 Tf 1 0 0 1 61.82 29.31 Tm (Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association. ) Tj ET BT /F4 7 Tf 1 0 0 1 0 21.26 Tm (Page ) Tj ET BT /F4 7 Tf 1 0 0 1 18.29 21.26 Tm (3) Tj ET BT /F4 7 Tf 1 0 0 1 22.19 21.26 Tm ( of ) Tj ET BT /F4 7 Tf 1 0 0 1 31.91 21.26 Tm (5 ) Tj ET BT /F4 8 Tf 1 0 0 1 486.61 20.36 Tm (000021958841 ) Tj ET Q q Q EMC q 1 0 0 1 36 712.9 cm /Artifact <> BDC 0.83922 0.84314 0.9098 RG 0 J 17.25 w -1.45 33.77 m 220.25 33.77 l S 1 w 17.25 w 220.75 33.77 m 542.6 33.77 l S 1 w 1 1 1 RG 22.27 w -1.45 13.51 m 220.25 13.51 l S 1 w 0.92941 0.95294 0.99608 RG 22.4 w 220.5 13.57 m 542.6 13.57 l S 1 w 0.86275 0.86275 0.86275 RG -1.45 1.5 m 542.6 1.5 l S EMC /Artifact <> BDC 0.2 0.2 0.2 rg BT /F3 9 Tf 1 0 0 1 2.9 30.8 Tm (Benefits ) Tj ET BT /F3 9 Tf 1 0 0 1 224.85 30.8 Tm (Coverage ) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 2.9 15.41 Tm (Tissue conditioning ) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 223.4 15.53 Tm (80% of approved amount ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 223.4 6.33 Tm (Note:) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 243.84 6.33 Tm ( Once per arch in any 36 consecutive months ) Tj ET EMC q n 2.9 2 m 546.95 2 l 546.95 1 l 2.9 1 l h W n Q /Artifact <> BDC 2 J 0.5 w [] 0 d 1 1 1 RG 220.5 42.4 m 220.5 2.38 l S 1 w [] 0 d 0.5 w [] 0 d 542.85 42.4 m 542.85 1 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 24.9 m 542.35 24.9 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 2.13 m 542.35 2.13 l S 1 w [] 0 d EMC q n 0 1 m 612 1 l 612 0 l 0 0 l h W n Q Q q Q q 1 0 0 1 36 554.48 cm /Artifact <> BDC 0.41961 0.53333 0.83137 RG 0 J 20.7 w -1.45 134.64 m 542.6 134.64 l S 1 w 0.83922 0.84314 0.9098 RG 17.25 w -1.45 115.67 m 220.25 115.67 l S 1 w 17.25 w 220.75 115.67 m 542.6 115.67 l S 1 w 1 1 1 RG 22.27 w -1.45 95.41 m 220.25 95.41 l S 1 w 0.92941 0.95294 0.99608 RG 22.4 w 220.5 95.47 m 542.6 95.47 l S 1 w 0.86275 0.86275 0.86275 RG 1.25 w -1.45 83.27 m 542.6 83.27 l S 1 w 1 1 1 RG 22.4 w -1.45 71.2 m 220.25 71.2 l S 1 w 0.92941 0.95294 0.99608 RG 22.52 w 220.5 71.26 m 542.6 71.26 l S 1 w 0.86275 0.86275 0.86275 RG 1.25 w -1.45 59 m 542.6 59 l S 1 w 1 1 1 RG 31.47 w -1.45 42.38 m 220.25 42.38 l S 1 w 0.92941 0.95294 0.99608 RG 31.6 w 220.5 42.45 m 542.6 42.45 l S 1 w 0.86275 0.86275 0.86275 RG 1.25 w -1.45 25.65 m 542.6 25.65 l S 1 w 1 1 1 RG 22.4 w -1.45 13.57 m 220.25 13.57 l S 1 w 0.92941 0.95294 0.99608 RG 22.52 w 220.5 13.64 m 542.6 13.64 l S 1 w 0.86275 0.86275 0.86275 RG -1.45 1.5 m 542.6 1.5 l S EMC /Span <>BDC 1 1 1 rg BT /F3 12 Tf 1 0 0 1 2.9 130.68 Tm (Class III services ) Tj ET EMC /Span <>BDC 0.2 0.2 0.2 rg BT /F3 9 Tf 1 0 0 1 2.9 112.69 Tm (Benefits ) Tj ET EMC /Span <>BDC BT /F3 9 Tf 1 0 0 1 224.85 112.69 Tm (Coverage ) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 2.9 97.3 Tm (Removable dentures $complete and partial$ ) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 223.4 97.43 Tm (50% of approved amount ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 223.4 88.23 Tm (Note:) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 243.84 88.23 Tm ( Once every 60 months ) Tj ET EMC q n 2.9 83.89 m 546.95 83.89 l 546.95 82.89 l 2.9 82.89 l h W n Q /Span <>BDC 0.2 0.2 0.2 rg BT /F4 8 Tf 1 0 0 1 2.9 73.15 Tm (Bridges $fixed partial dentures$ - for members age 16 and ) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 2.9 63.95 Tm (older ) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 223.4 73.28 Tm (50% of approved amount ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 223.4 64.08 Tm (Note:) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 243.84 64.08 Tm ( Once every 60 months ) Tj ET EMC q n 2.9 59.62 m 546.95 59.62 l 546.95 58.62 l 2.9 58.62 l h W n Q /Span <>BDC 0.2 0.2 0.2 rg BT /F4 8 Tf 1 0 0 1 2.9 48.88 Tm (Endosteal implants - for members age 16 or older who are ) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 2.9 39.68 Tm (covered at the time of the actual implant placement ) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 223.4 49 Tm (50% of approved amount ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 223.4 39.81 Tm (Note:) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 243.84 39.81 Tm ( Once per tooth per lifetime when implant placement is for teeth numbered 2 ) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 223.4 30.61 Tm (through 15 and 18 through 31 ) Tj ET EMC q n 2.9 26.27 m 546.95 26.27 l 546.95 25.27 l 2.9 25.27 l h W n Q /Span <>BDC 0.2 0.2 0.2 rg BT /F4 8 Tf 1 0 0 1 2.9 15.53 Tm (Crowns, onlays, inlays, and veneer restorations - permanent ) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 2.9 6.33 Tm (teeth - for members age 12 and older ) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 223.4 15.66 Tm (50% of approved amount ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 223.4 6.46 Tm (Note:) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 243.84 6.46 Tm ( Once every 60 months per tooth ) Tj ET EMC q n 2.9 2 m 546.95 2 l 546.95 1 l 2.9 1 l h W n Q /Artifact <> BDC 2 J 0.5 w [] 0 d 1 1 1 RG 220.5 124.29 m 220.5 84.27 l S 1 w [] 0 d 0.5 w [] 0 d 220.5 82.39 m 220.5 59.99 l S 1 w [] 0 d 0.5 w [] 0 d 220.5 58.12 m 220.5 26.65 l S 1 w [] 0 d 0.5 w [] 0 d 220.5 24.77 m 220.5 2.38 l S 1 w [] 0 d 0.5 w [] 0 d 542.85 144.99 m 542.85 1 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 106.79 m 542.35 106.79 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 84.02 m 542.35 84.02 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 82.64 m 220.5 82.64 l S 1 w [] 0 d 0 J 0.25 w [1 1] 0 d 0.86275 0.86275 0.86275 RG 220.75 82.64 m 542.6 82.64 l S 1 w [] 0 d 2 J 0.5 w [] 0 d 1 1 1 RG -1.2 59.74 m 542.35 59.74 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 58.37 m 220.5 58.37 l S 1 w [] 0 d 0 J 0.25 w [1 1] 0 d 0.86275 0.86275 0.86275 RG 220.75 58.37 m 542.6 58.37 l S 1 w [] 0 d 2 J 0.5 w [] 0 d 1 1 1 RG -1.2 26.4 m 542.35 26.4 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 25.02 m 220.5 25.02 l S 1 w [] 0 d 0 J 0.25 w [1 1] 0 d 0.86275 0.86275 0.86275 RG 220.75 25.02 m 542.6 25.02 l S 1 w [] 0 d 2 J 0.5 w [] 0 d 1 1 1 RG -1.2 2.13 m 542.35 2.13 l S 1 w [] 0 d EMC q n 0 1 m 612 1 l 612 0 l 0 0 l h W n Q Q q Q q 1 0 0 1 36 87.75 cm /Artifact <> BDC 0.41961 0.53333 0.83137 RG 0 J 20.7 w -1.45 442.96 m 542.6 442.96 l S 1 w 0.83922 0.84314 0.9098 RG 17.25 w -1.45 423.99 m 220.25 423.99 l S 1 w 17.25 w 220.75 423.99 m 542.6 423.99 l S 1 w 1 1 1 RG 13.2 w -1.45 408.26 m 220.25 408.26 l S 1 w 0.92941 0.95294 0.99608 RG 13.32 w 220.5 408.33 m 542.6 408.33 l S 1 w 0.86275 0.86275 0.86275 RG 1.25 w -1.45 400.66 m 542.6 400.66 l S 1 w 1 1 1 RG 13.2 w -1.45 393.19 m 220.25 393.19 l S 1 w 0.92941 0.95294 0.99608 RG 13.32 w 220.5 393.25 m 542.6 393.25 l S 1 w 0.86275 0.86275 0.86275 RG 1.25 w -1.45 385.59 m 542.6 385.59 l S 1 w 1 1 1 RG 13.2 w -1.45 378.11 m 220.25 378.11 l S 1 w 0.92941 0.95294 0.99608 RG 13.32 w 220.5 378.18 m 542.6 378.18 l S 1 w 0.86275 0.86275 0.86275 RG 1.25 w -1.45 370.51 m 542.6 370.51 l S 1 w 1 1 1 RG 13.2 w -1.45 363.04 m 220.25 363.04 l S 1 w 0.92941 0.95294 0.99608 RG 13.32 w 220.5 363.1 m 542.6 363.1 l S 1 w 0.86275 0.86275 0.86275 RG 1.25 w -1.45 355.44 m 542.6 355.44 l S 1 w 1 1 1 RG 13.2 w -1.45 347.97 m 220.25 347.97 l S 1 w 0.92941 0.95294 0.99608 RG 13.32 w 220.5 348.03 m 542.6 348.03 l S 1 w 0.86275 0.86275 0.86275 RG -1.45 340.49 m 542.6 340.49 l S EMC /Span <>BDC 1 1 1 rg BT /F3 12 Tf 1 0 0 1 2.9 439 Tm (Class IV services) Tj ET EMC /Span <>BDC BT /F4 12 Tf 1 0 0 1 100.97 439 Tm ( ) Tj ET EMC /Span <>BDC BT /F3 12 Tf 1 0 0 1 104.31 439 Tm (- Orthodontic services for dependents under age 19 ) Tj ET EMC /Span <>BDC 0.2 0.2 0.2 rg BT /F3 9 Tf 1 0 0 1 2.9 421.01 Tm (Benefits ) Tj ET EMC /Span <>BDC BT /F3 9 Tf 1 0 0 1 224.85 421.01 Tm (Coverage ) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 2.9 405.62 Tm (Minor treatment for tooth guidance appliances ) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 223.4 405.75 Tm (50% of approved amount ) Tj ET EMC q n 2.9 401.29 m 546.95 401.29 l 546.95 400.29 l 2.9 400.29 l h W n Q /Span <>BDC 0.2 0.2 0.2 rg BT /F4 8 Tf 1 0 0 1 2.9 390.55 Tm (Minor treatment to control harmful habits ) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 223.4 390.67 Tm (50% of approved amount ) Tj ET EMC q n 2.9 386.21 m 546.95 386.21 l 546.95 385.21 l 2.9 385.21 l h W n Q /Span <>BDC 0.2 0.2 0.2 rg BT /F4 8 Tf 1 0 0 1 2.9 375.47 Tm (Interceptive and comprehensive orthodontic treatment ) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 223.4 375.6 Tm (50% of approved amount ) Tj ET EMC q n 2.9 371.14 m 546.95 371.14 l 546.95 370.14 l 2.9 370.14 l h W n Q /Span <>BDC 0.2 0.2 0.2 rg BT /F4 8 Tf 1 0 0 1 2.9 360.4 Tm (Post-treatment stabilization ) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 223.4 360.52 Tm (50% of approved amount ) Tj ET EMC q n 2.9 356.07 m 546.95 356.07 l 546.95 355.07 l 2.9 355.07 l h W n Q /Span <>BDC 0.2 0.2 0.2 rg BT /F4 8 Tf 1 0 0 1 2.9 345.32 Tm (Cephalometric film $skull$ and diagnostic photos ) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 223.4 345.45 Tm (50% of approved amount ) Tj ET EMC q n 2.9 340.99 m 546.95 340.99 l 546.95 339.99 l 2.9 339.99 l h W n Q /Artifact <> BDC 2 J 0.5 w [] 0 d 1 1 1 RG 220.5 432.61 m 220.5 401.66 l S 1 w [] 0 d 0.5 w [] 0 d 220.5 399.79 m 220.5 386.59 l S 1 w [] 0 d 0.5 w [] 0 d 220.5 384.71 m 220.5 371.51 l S 1 w [] 0 d 0.5 w [] 0 d 220.5 369.64 m 220.5 356.44 l S 1 w [] 0 d 0.5 w [] 0 d 220.5 354.57 m 220.5 341.37 l S 1 w [] 0 d 0.5 w [] 0 d 542.85 453.31 m 542.85 339.99 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 415.11 m 542.35 415.11 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 401.41 m 542.35 401.41 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 400.04 m 220.5 400.04 l S 1 w [] 0 d 0 J 0.25 w [1 1] 0 d 0.86275 0.86275 0.86275 RG 220.75 400.04 m 542.6 400.04 l S 1 w [] 0 d 2 J 0.5 w [] 0 d 1 1 1 RG -1.2 386.34 m 542.35 386.34 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 384.96 m 220.5 384.96 l S 1 w [] 0 d 0 J 0.25 w [1 1] 0 d 0.86275 0.86275 0.86275 RG 220.75 384.96 m 542.6 384.96 l S 1 w [] 0 d 2 J 0.5 w [] 0 d 1 1 1 RG -1.2 371.26 m 542.35 371.26 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 369.89 m 220.5 369.89 l S 1 w [] 0 d 0 J 0.25 w [1 1] 0 d 0.86275 0.86275 0.86275 RG 220.75 369.89 m 542.6 369.89 l S 1 w [] 0 d 2 J 0.5 w [] 0 d 1 1 1 RG -1.2 356.19 m 542.35 356.19 l S 1 w [] 0 d 0.5 w [] 0 d -1.2 354.82 m 220.5 354.82 l S 1 w [] 0 d 0 J 0.25 w [1 1] 0 d 0.86275 0.86275 0.86275 RG 220.75 354.82 m 542.6 354.82 l S 1 w [] 0 d 2 J 0.5 w [] 0 d 1 1 1 RG -1.2 341.11 m 542.35 341.11 l S 1 w [] 0 d EMC q n 0 339.99 m 612 339.99 l 612 338.99 l 0 338.99 l h W n Q /Span <>BDC 0 0 0 rg BT /F3 8 Tf 1 0 0 1 0 329.75 Tm (Note:) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 20.44 329.75 Tm ( For non-urgent, complex or expensive dental treatment such as crowns, bridges or dentures, members should encourage their dentist to submit ) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 0 320.55 Tm (the claim to Blue Cross for predetermination ) Tj ET EMC /Span <>BDC BT /F150 8 Tf 1 0 0 1 158.29 320.55 Tm (before) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 182.74 320.55 Tm ( treatment begins. ) Tj ET EMC Q q Q Q endstream endobj 152 0 obj <>/Font<>>>>> endobj 153 0 obj <> endobj 155 0 obj <> endobj 156 0 obj <> endobj 157 0 obj <> endobj 158 0 obj <> endobj 159 0 obj <> endobj 160 0 obj <> endobj 161 0 obj <> endobj 162 0 obj <> endobj 163 0 obj <> endobj 164 0 obj <> endobj 165 0 obj <> endobj 166 0 obj <> endobj 167 0 obj <> endobj 168 0 obj <>/Pg 152 0 R /K[<>]/Type/StructElem/Alt(þÿBlue Cross Blue Shield of Michigan. A nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.)/S/Figure/Lang(en_US)/P 169 0 R >> endobj 169 0 obj <> endobj 170 0 obj <> endobj 171 0 obj <> endobj 172 0 obj <> endobj 173 0 obj <> endobj 174 0 obj <> endobj 175 0 obj <> endobj 177 0 obj <> endobj 179 0 obj [ 152 0 R /XYZ 38.9 415.24 0] endobj 180 0 obj [ 152 0 R /XYZ 38.9 415.24 0] endobj 181 0 obj <> endobj 183 0 obj <> endobj 184 0 obj <> endobj 185 0 obj <> endobj 186 0 obj <> endobj 187 0 obj <> endobj 188 0 obj <> endobj 189 0 obj <> endobj 190 0 obj <> endobj 191 0 obj <> endobj 192 0 obj <> endobj 193 0 obj <> endobj 194 0 obj <> endobj 195 0 obj <> endobj 196 0 obj [ 152 0 R /XYZ 38.9 258.1 0] endobj 197 0 obj [ 152 0 R /XYZ 38.9 258.1 0] endobj 198 0 obj <> endobj 200 0 obj <> endobj 201 0 obj <> endobj 202 0 obj <> endobj 203 0 obj <> endobj 204 0 obj <> endobj 205 0 obj <> endobj 206 0 obj <> endobj 207 0 obj <>stream q 0 0 612 792 re W n /Artifact <> BDC EMC /Artifact <> BDC q 1 0 0 1 36 36 cm 0 0 0 rg BT /F3 7 Tf 1 0 0 1 143.01 43.76 Tm (ADM PLANYR JAN;BLUE DENTAL;DO-PPO;ESS VIS;EVC $7.50;EVFL;PK616 ) Tj ET BT /F4 7 Tf 1 0 0 1 61.82 27.66 Tm (Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association. ) Tj ET BT /F4 7 Tf 1 0 0 1 0 3.56 Tm (Page ) Tj ET BT /F4 7 Tf 1 0 0 1 18.29 3.56 Tm (4) Tj ET BT /F4 7 Tf 1 0 0 1 22.19 3.56 Tm ( of ) Tj ET BT /F4 7 Tf 1 0 0 1 31.91 3.56 Tm (5 ) Tj ET BT /F4 7 Tf 1 0 0 1 493.28 3.56 Tm (000021958841 ) Tj ET q n 0 0.7 m 612 0.7 l 612 0 l 0 0 l h W n Q Q q Q EMC q 1 0 0 1 36 529.08 cm q 1 0 0 1 0 121.89 cm q n 0 0 m 540 0 l 540 91.6 l 0 91.6 l h W n /Figure <>BDC q 540 0 0 91.6 0 0 cm /img1238252 Do Q EMC Q Q q Q /Span <>BDC 0 0 0 rg BT /F3 14 Tf 1 0 0 1 0 100.02 Tm (LAKE SUPERIOR STATE UNIVERSI ) Tj ET EMC /Span <>BDC BT /F3 14 Tf 1 0 0 1 0 83.92 Tm (A1PSR9 ) Tj ET EMC /Span <>BDC BT /F3 14 Tf 1 0 0 1 0 67.82 Tm (0070041760001 ) Tj ET EMC /Span <>BDC BT /F3 14 Tf 1 0 0 1 0 51.72 Tm (Vision Coverage ) Tj ET EMC /Span <>BDC BT /F3 14 Tf 1 0 0 1 0 35.62 Tm (Effective Date:) Tj ET EMC /Span <>BDC BT /F3 14 Tf 1 0 0 1 97.26 35.62 Tm ( On or after ) Tj ET EMC /Span <>BDC BT /F3 14 Tf 1 0 0 1 180.49 35.62 Tm (January 2025 ) Tj ET EMC /Span <>BDC BT /F3 14 Tf 1 0 0 1 0 19.52 Tm (Benefits-at-a-glance ) Tj ET EMC Q q Q q 1 0 0 1 36 418.69 cm /Span <>BDC 0 0 0 rg BT /F4 8 Tf 1 0 0 1 0 103.15 Tm (This is intended as an easy-to-read summary and provides only a general overview of your benefits. It is not a contract. Additional limitations and ) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 0 93.95 Tm (exclusions may apply. Payment amounts are based on BCBSM's approved amount, less any applicable deductible and/or copay. For a complete ) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 0 84.75 Tm (description of benefits please see the applicable BCBSM certificates and riders, if your group is underwritten. If your group is self-funded, please see ) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 0 75.55 Tm (any other plan documents your group uses. If there is a discrepancy between this Benefits-at-a-Glance and any applicable plan document, the plan ) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 0 66.35 Tm (document will control. ) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 0 47.95 Tm (Essential Vision benefits are provided by Heritage Vision Plans. Heritage Vision Plans is an independent company providing vision benefit services ) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 0 38.75 Tm (for Blues members. To find a Heritage Vision Plans network provider, call ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 261.45 38.75 Tm (1-800-252-2053) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 318.38 38.75 Tm ( or visit Heritage Vision Plans online at ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 0 29.56 Tm (heritagevisionplans.com) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 93.81 29.56 Tm (. ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 0 11.16 Tm (Note:) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 20.44 11.16 Tm ( Members may choose between prescription glasses $lenses and frame$ ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 277.89 11.16 Tm (or) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 285.89 11.16 Tm ( contact lenses, but not both. ) Tj ET EMC Q q Q q 1 0 0 1 36 270.75 cm /Artifact <> BDC 0.41961 0.53333 0.83137 RG 0 J 20.7 w -1.45 137.59 m 542.6 137.59 l S 1 w 0.83922 0.84314 0.9098 RG 17.25 w -1.45 118.62 m 269.85 118.62 l S 1 w 17.25 w 270.35 118.62 m 418.9 118.62 l S 1 w 17.25 w 419.4 118.62 m 542.6 118.62 l S 1 w 1 1 1 RG 13.2 w -1.45 103.39 m 269.85 103.39 l S 1 w 0.92941 0.95294 0.99608 RG 13.2 w 270.35 103.39 m 418.9 103.39 l S 1 w 0.96078 0.96078 0.96078 RG 13.2 w 419.4 103.39 m 542.6 103.39 l S 1 w 0.86275 0.86275 0.86275 RG -1.45 96.29 m 542.6 96.29 l S 1 1 1 RG 40.8 w -1.45 75.39 m 269.85 75.39 l S 1 w 0.92941 0.95294 0.99608 RG 40.8 w 270.35 75.39 m 418.9 75.39 l S 1 w 0.96078 0.96078 0.96078 RG 40.8 w 419.4 75.39 m 542.6 75.39 l S 1 w 0.86275 0.86275 0.86275 RG -1.45 54.5 m 542.6 54.5 l S 1 1 1 RG 52 w -1.45 28 m 269.85 28 l S 1 w 0.92941 0.95294 0.99608 RG 52 w 270.35 28 m 418.9 28 l S 1 w 0.96078 0.96078 0.96078 RG 52 w 419.4 28 m 542.6 28 l S 1 w 0.86275 0.86275 0.86275 RG -1.45 1.5 m 542.6 1.5 l S EMC /Span <>BDC 1 1 1 rg BT /F3 12 Tf 1 0 0 1 2.9 133.63 Tm (Member's responsibility $copays$ ) Tj ET EMC /Span <>BDC 0.2 0.2 0.2 rg BT /F3 9 Tf 1 0 0 1 2.9 115.64 Tm (Benefits ) Tj ET EMC /Span <>BDC BT /F3 9 Tf 1 0 0 1 274.45 115.64 Tm (Network doctor ) Tj ET EMC /Span <>BDC BT /F3 9 Tf 1 0 0 1 422.3 117.09 Tm (Non-network provider ) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 2.9 100.75 Tm (Eye exam ) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 273.25 100.75 Tm ($5 copay ) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 422.3 100.75 Tm ($5 copay applies to charge ) Tj ET EMC q n 2.9 96.79 m 546.95 96.79 l 546.95 95.79 l 2.9 95.79 l h W n Q /Span <>BDC 0.2 0.2 0.2 rg BT /F4 8 Tf 1 0 0 1 2.9 86.55 Tm (Prescription glasses $lenses and/or frames$ ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 273.25 86.55 Tm (Combined) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 312.36 86.55 Tm ( $7.50 copay ) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 422.3 86.55 Tm (Member responsible for ) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 422.3 77.35 Tm (difference between approved ) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 422.3 68.15 Tm (amount and provider's charge, ) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 422.3 58.95 Tm (after $7.50 copay ) Tj ET EMC q n 2.9 55 m 546.95 55 l 546.95 54 l 2.9 54 l h W n Q /Span <>BDC 0.2 0.2 0.2 rg BT /F4 8 Tf 1 0 0 1 2.9 44.75 Tm (Medically necessary contact lenses ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 2.9 15.16 Tm (Note:) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 23.34 15.16 Tm ( No copay is required for prescribed contact lenses that are not ) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 2.9 5.96 Tm (medically necessary. ) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 273.25 44.75 Tm ($7.50 copay ) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 422.3 44.75 Tm (Member responsible for ) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 422.3 35.56 Tm (difference between approved ) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 422.3 26.36 Tm (amount and provider's charge, ) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 422.3 17.16 Tm (after $7.50 copay ) Tj ET EMC q n 2.9 2 m 546.95 2 l 546.95 1 l 2.9 1 l h W n Q /Artifact <> BDC 2 J 0.5 w [] 0 d 1 1 1 RG 270.1 127.24 m 270.1 96.79 l S 1 w [] 0 d 0.5 w [] 0 d 270.1 95.79 m 270.1 54.99 l S 1 w [] 0 d 0.5 w [] 0 d 270.1 53.99 m 270.1 2 l S 1 w [] 0 d 0.5 w [] 0 d 419.15 127.24 m 419.15 96.79 l S 1 w [] 0 d 0.5 w [] 0 d 419.15 95.79 m 419.15 54.99 l S 1 w [] 0 d 0.5 w [] 0 d 419.15 53.99 m 419.15 2 l S 1 w [] 0 d 0.5 w [] 0 d 542.85 147.94 m 542.85 1 l S 1 w [] 0 d EMC q n 0 1 m 612 1 l 612 0 l 0 0 l h W n Q Q q Q q 1 0 0 1 36 176.81 cm /Artifact <> BDC 0.41961 0.53333 0.83137 RG 0 J 20.7 w -1.45 74.4 m 542.6 74.4 l S 1 w 0.83922 0.84314 0.9098 RG 17.25 w -1.45 55.42 m 269.85 55.42 l S 1 w 17.25 w 270.35 55.42 m 418.9 55.42 l S 1 w 17.25 w 419.4 55.42 m 542.6 55.42 l S 1 w 1 1 1 RG 44.8 w -1.45 24.4 m 269.85 24.4 l S 1 w 0.92941 0.95294 0.99608 RG 31.6 w 270.35 31 m 418.9 31 l S 1 w 0.96078 0.96078 0.96078 RG 31.6 w 419.4 31 m 542.6 31 l S 1 w 1 1 1 RG 13.2 w 270.35 8.6 m 542.6 8.6 l S 1 w 0.86275 0.86275 0.86275 RG -1.45 1.5 m 542.6 1.5 l S EMC /Span <>BDC 1 1 1 rg BT /F3 12 Tf 1 0 0 1 2.9 70.43 Tm (Eye exam ) Tj ET EMC /Span <>BDC 0.2 0.2 0.2 rg BT /F3 9 Tf 1 0 0 1 2.9 52.45 Tm (Benefits ) Tj ET EMC /Span <>BDC BT /F3 9 Tf 1 0 0 1 274.45 52.45 Tm (Network doctor ) Tj ET EMC /Span <>BDC BT /F3 9 Tf 1 0 0 1 422.3 53.9 Tm (Non-network provider ) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 2.9 37.56 Tm (Complete eye exam by an ophthalmologist or optometrist. The exam ) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 2.9 28.36 Tm (includes refraction, glaucoma testing and other tests necessary to ) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 2.9 19.16 Tm (determine the overall visual health of the patient. ) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 273.25 37.56 Tm ($5 copay ) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 422.3 37.56 Tm (Reimbursement up to $35 less $5 ) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 422.3 28.36 Tm (copay $member responsible for ) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 422.3 19.16 Tm (any difference$ ) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 309.43 5.96 Tm (One eye exam in any period of 12 ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 431.72 5.96 Tm (consecutive) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 477.97 5.96 Tm ( months ) Tj ET EMC q n 2.9 2 m 546.95 2 l 546.95 1 l 2.9 1 l h W n Q /Artifact <> BDC 2 J 0.5 w [] 0 d 1 1 1 RG 270.1 64.04 m 270.1 2 l S 1 w [] 0 d 0.5 w [] 0 d 419.15 64.04 m 419.15 15.2 l S 1 w [] 0 d 0.5 w [] 0 d 542.85 84.75 m 542.85 1 l S 1 w [] 0 d EMC q n 0 1 m 612 1 l 612 0 l 0 0 l h W n Q Q q Q Q endstream endobj 208 0 obj <>>>>> endobj 209 0 obj [ 208 0 R /XYZ 38.9 739.12 0] endobj 210 0 obj [ 208 0 R /XYZ 38.9 739.12 0] endobj 211 0 obj <> endobj 213 0 obj <> endobj 214 0 obj <> endobj 215 0 obj <> endobj 216 0 obj <> endobj 217 0 obj <> endobj 218 0 obj <> endobj 219 0 obj <> endobj 220 0 obj <> endobj 221 0 obj <> endobj 222 0 obj <> endobj 223 0 obj <> endobj 224 0 obj [ 208 0 R /XYZ 38.9 548.19 0] endobj 225 0 obj [ 208 0 R /XYZ 38.9 548.19 0] endobj 226 0 obj <> endobj 228 0 obj <> endobj 229 0 obj <> endobj 230 0 obj <> endobj 231 0 obj <> endobj 232 0 obj <> endobj 233 0 obj <> endobj 234 0 obj <> endobj 235 0 obj <> endobj 236 0 obj <> endobj 237 0 obj <> endobj 238 0 obj <> endobj 14 0 obj <> endobj 16 0 obj <> endobj 21 0 obj <> endobj 240 0 obj <> endobj 39 0 obj <> endobj 64 0 obj <> endobj 241 0 obj <> endobj 80 0 obj <> endobj 242 0 obj <> endobj 106 0 obj <> endobj 132 0 obj <> endobj 243 0 obj <> endobj 137 0 obj <> endobj 244 0 obj <> endobj 154 0 obj <> endobj 176 0 obj <> endobj 178 0 obj <> endobj 182 0 obj <> endobj 245 0 obj <> endobj 199 0 obj <> endobj 246 0 obj <> endobj 247 0 obj <> endobj 212 0 obj <> endobj 248 0 obj <> endobj 227 0 obj <> endobj 249 0 obj <> endobj 239 0 obj <> endobj 250 0 obj [ 6 0 R 8 0 R 9 0 R 10 0 R 11 0 R 12 0 R 12 0 R 12 0 R 13 0 R 15 0 R 15 0 R 15 0 R 15 0 R 15 0 R 15 0 R 15 0 R 15 0 R 15 0 R 15 0 R 15 0 R 15 0 R 15 0 R 15 0 R 15 0 R 15 0 R 15 0 R 15 0 R 15 0 R 15 0 R 15 0 R 15 0 R 15 0 R 15 0 R 15 0 R 20 0 R 22 0 R 23 0 R 24 0 R 25 0 R 27 0 R 29 0 R 31 0 R 31 0 R 31 0 R 38 0 R 40 0 R 41 0 R 42 0 R 43 0 R 44 0 R 44 0 R 45 0 R 47 0 R 49 0 R 50 0 R 52 0 R 54 0 R 55 0 R 57 0 R 59 0 R ] endobj 251 0 obj [ 60 0 R 62 0 R 65 0 R 66 0 R 67 0 R 69 0 R 71 0 R 72 0 R 74 0 R 76 0 R 79 0 R 81 0 R 82 0 R 83 0 R 84 0 R 84 0 R 84 0 R 85 0 R 86 0 R 86 0 R 86 0 R 87 0 R 88 0 R 88 0 R 88 0 R 89 0 R 90 0 R 90 0 R 90 0 R 91 0 R 92 0 R 92 0 R 92 0 R 92 0 R 93 0 R 94 0 R 95 0 R 96 0 R 96 0 R 96 0 R 97 0 R 97 0 R 98 0 R 98 0 R 98 0 R 99 0 R 100 0 R 105 0 R 107 0 R 108 0 R 109 0 R 110 0 R 110 0 R 110 0 R 111 0 R 112 0 R 112 0 R 112 0 R 113 0 R 113 0 R 114 0 R 114 0 R 114 0 R 115 0 R 116 0 R 117 0 R 118 0 R 118 0 R 118 0 R 118 0 R 119 0 R 120 0 R 120 0 R 120 0 R 121 0 R 122 0 R 122 0 R 122 0 R 122 0 R 122 0 R 122 0 R 123 0 R 124 0 R 124 0 R 124 0 R 125 0 R 126 0 R 126 0 R 126 0 R 127 0 R 128 0 R 128 0 R 128 0 R 129 0 R 130 0 R 130 0 R 130 0 R ] endobj 252 0 obj [ 131 0 R 133 0 R 133 0 R 133 0 R 136 0 R 138 0 R 139 0 R 140 0 R 141 0 R 141 0 R 141 0 R 142 0 R 142 0 R 143 0 R 143 0 R 143 0 R 144 0 R 144 0 R 145 0 R 145 0 R 145 0 R 145 0 R 146 0 R 146 0 R 147 0 R 147 0 R 147 0 R 153 0 R 153 0 R 153 0 R 155 0 R 156 0 R 157 0 R 158 0 R 159 0 R 160 0 R 161 0 R 162 0 R 163 0 R 164 0 R 165 0 R 166 0 R 167 0 R 167 0 R 167 0 R 167 0 R 167 0 R ] endobj 253 0 obj [ 168 0 R 170 0 R 171 0 R 172 0 R 173 0 R 174 0 R 174 0 R 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0 R ] endobj 255 0 obj <>stream q 0 0 612 792 re W n /Artifact <> BDC EMC /Artifact <> BDC q 1 0 0 1 36 36 cm 0 0 0 rg BT /F3 7 Tf 1 0 0 1 143.01 43.76 Tm (ADM PLANYR JAN;BLUE DENTAL;DO-PPO;ESS VIS;EVC $7.50;EVFL;PK616 ) Tj ET BT /F4 7 Tf 1 0 0 1 61.82 27.66 Tm (Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association. ) Tj ET BT /F4 7 Tf 1 0 0 1 0 3.56 Tm (Page ) Tj ET BT /F4 7 Tf 1 0 0 1 18.29 3.56 Tm (5) Tj ET BT /F4 7 Tf 1 0 0 1 22.19 3.56 Tm ( of ) Tj ET BT /F4 7 Tf 1 0 0 1 31.91 3.56 Tm (5 ) Tj ET BT /F4 7 Tf 1 0 0 1 493.28 3.56 Tm (000021958841 ) Tj ET q n 0 0.7 m 612 0.7 l 612 0 l 0 0 l h W n Q Q q Q EMC q 1 0 0 1 36 560.84 cm /Artifact <> BDC 0.41961 0.53333 0.83137 RG 0 J 20.7 w -1.45 171.39 m 542.6 171.39 l S 1 w 0.83922 0.84314 0.9098 RG 17.25 w -1.45 152.41 m 269.85 152.41 l S 1 w 17.25 w 270.35 152.41 m 418.9 152.41 l S 1 w 17.25 w 419.4 152.41 m 542.6 152.41 l S 1 w 1 1 1 RG 77.59 w -1.45 104.99 m 269.85 104.99 l S 1 w 0.92941 0.95294 0.99608 RG 40.8 w 270.35 123.39 m 418.9 123.39 l S 1 w 0.96078 0.96078 0.96078 RG 40.8 w 419.4 123.39 m 542.6 123.39 l S 1 w 1 1 1 RG 36.8 w 270.35 84.59 m 542.6 84.59 l S 1 w 0.86275 0.86275 0.86275 RG -1.45 65.69 m 542.6 65.69 l S 1 1 1 RG 63.19 w -1.45 33.6 m 269.85 33.6 l S 1 w 0.92941 0.95294 0.99608 RG 50 w 270.35 40.2 m 418.9 40.2 l S 1 w 0.96078 0.96078 0.96078 RG 50 w 419.4 40.2 m 542.6 40.2 l S 1 w 1 1 1 RG 13.2 w 270.35 8.6 m 542.6 8.6 l S 1 w 0.86275 0.86275 0.86275 RG -1.45 1.5 m 542.6 1.5 l S EMC /Span <>BDC 1 1 1 rg BT /F3 12 Tf 1 0 0 1 2.9 167.42 Tm (Lenses and frames ) Tj ET EMC /Span <>BDC 0.2 0.2 0.2 rg BT /F3 9 Tf 1 0 0 1 2.9 149.44 Tm (Benefits ) Tj ET EMC /Span <>BDC BT /F3 9 Tf 1 0 0 1 274.45 149.44 Tm (Network doctor ) Tj ET EMC /Span <>BDC BT /F3 9 Tf 1 0 0 1 422.3 150.89 Tm (Non-network provider ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 2.9 134.55 Tm (Standard lenses) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 64.7 134.55 Tm ( $must not exceed 60 mm in diameter$ prescribed and ) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 2.9 125.35 Tm (dispensed by an ophthalmologist or optometrist. Lenses may be molded or ) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 2.9 116.15 Tm (ground, glass or plastic. Also covers prism, slab-off prism and special base ) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 2.9 106.95 Tm (curve lenses when medically necessary. ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 2.9 88.55 Tm (Note:) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 23.34 88.55 Tm ( Preferred pricing discounts on noncovered lens options and ) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 2.9 79.35 Tm (upgrades, and on an additional prescription eyeglass or sunglass $second ) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 2.9 70.15 Tm (pair$ purchase when obtained from a network provider. ) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 273.25 134.55 Tm ($7.50 copay $one copay applies to ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 397.34 134.55 Tm (both ) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 273.25 125.35 Tm (lenses and frames$ ) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 422.3 134.55 Tm (Reimbursement up to approved ) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 422.3 125.35 Tm (amount based on lens type less ) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 422.3 116.15 Tm ($7.50 copay $member ) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 422.3 106.95 Tm (responsible for any difference$ ) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 274.97 93.75 Tm (One pair of lenses, with or without frames, in any period of 12 ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 494.64 93.75 Tm (consecutive ) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 394.81 84.55 Tm (months ) Tj ET EMC q n 2.9 66.19 m 546.95 66.19 l 546.95 65.19 l 2.9 65.19 l h W n Q /Span <>BDC 0.2 0.2 0.2 rg BT /F4 8 Tf 1 0 0 1 2.9 55.95 Tm (Standard frames ) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 273.25 55.95 Tm ($130 allowance that is applied toward ) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 273.25 46.75 Tm (frames $member responsible for any cost ) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 273.25 37.56 Tm (exceeding the allowance$ less $7.50 ) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 273.25 28.36 Tm (copay $one copay applies to ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 375.09 28.36 Tm (both ) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 273.25 19.16 Tm (frames and lenses$ ) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 422.3 55.95 Tm (Reimbursement up to $65 less ) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 422.3 46.75 Tm ($7.50 copay $member ) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 422.3 37.56 Tm (responsible for any difference$ ) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 316.54 5.96 Tm (One frame in any period of 12 ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 424.61 5.96 Tm (consecutive) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 470.85 5.96 Tm ( months ) Tj ET EMC q n 2.9 2 m 546.95 2 l 546.95 1 l 2.9 1 l h W n Q /Artifact <> BDC 2 J 0.5 w [] 0 d 1 1 1 RG 270.1 161.04 m 270.1 66.19 l S 1 w [] 0 d 0.5 w [] 0 d 270.1 65.19 m 270.1 2 l S 1 w [] 0 d 0.5 w [] 0 d 419.15 161.04 m 419.15 102.99 l S 1 w [] 0 d 0.5 w [] 0 d 419.15 65.19 m 419.15 15.2 l S 1 w [] 0 d 0.5 w [] 0 d 542.85 181.74 m 542.85 1 l S 1 w [] 0 d EMC q n 0 1 m 612 1 l 612 0 l 0 0 l h W n Q Q q Q q 1 0 0 1 36 375.1 cm /Artifact <> BDC 0.41961 0.53333 0.83137 RG 0 J 20.7 w -1.45 166.19 m 542.6 166.19 l S 1 w 0.83922 0.84314 0.9098 RG 17.25 w -1.45 147.21 m 269.85 147.21 l S 1 w 17.25 w 270.35 147.21 m 418.9 147.21 l S 1 w 17.25 w 419.4 147.21 m 542.6 147.21 l S 1 w 1 1 1 RG 54 w -1.45 111.59 m 269.85 111.59 l S 1 w 0.92941 0.95294 0.99608 RG 40.8 w 270.35 118.19 m 418.9 118.19 l S 1 w 0.96078 0.96078 0.96078 RG 40.8 w 419.4 118.19 m 542.6 118.19 l S 1 w 1 1 1 RG 13.2 w 270.35 91.19 m 542.6 91.19 l S 1 w 0.86275 0.86275 0.86275 RG -1.45 84.09 m 542.6 84.09 l S 1 1 1 RG 81.59 w -1.45 42.8 m 269.85 42.8 l S 1 w 0.92941 0.95294 0.99608 RG 59.19 w 270.35 54 m 418.9 54 l S 1 w 0.96078 0.96078 0.96078 RG 59.19 w 419.4 54 m 542.6 54 l S 1 w 1 1 1 RG 22.4 w 270.35 13.2 m 542.6 13.2 l S 1 w 0.86275 0.86275 0.86275 RG -1.45 1.5 m 542.6 1.5 l S EMC /Span <>BDC 1 1 1 rg BT /F3 12 Tf 1 0 0 1 2.9 162.22 Tm (Contact lenses ) Tj ET EMC /Span <>BDC 0.2 0.2 0.2 rg BT 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<>BDC BT /F3 8 Tf 1 0 0 1 467.75 88.55 Tm (consecutive) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 513.99 88.55 Tm ( months ) Tj ET EMC q n 2.9 84.59 m 546.95 84.59 l 546.95 83.59 l 2.9 83.59 l h W n Q /Span <>BDC 0.2 0.2 0.2 rg BT /F4 8 Tf 1 0 0 1 2.9 74.35 Tm (Elective contact lenses that ) Tj ET EMC /Span <>BDC BT /F3 8 Tf 1 0 0 1 102.06 74.35 Tm (improve) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 133.19 74.35 Tm ( vision $prescribed, but do not meet ) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 2.9 65.15 Tm (criteria of medically necessary$ ) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 273.25 74.35 Tm ($130 allowance that is applied toward ) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 273.25 65.15 Tm (contact lens exam $fitting and materials$ ) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 273.25 55.95 Tm (and the contact lenses $member ) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 273.25 46.75 Tm (responsible for any cost exceeding the ) Tj ET EMC /Span <>BDC BT /F4 8 Tf 1 0 0 1 273.25 37.56 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/Span <>BDC EMC /Span <>BDC EMC /Span <>BDC EMC /Span <>BDC EMC /Span <>BDC EMC /Span <>BDC EMC /Span <>BDC EMC /Span <>BDC EMC /Span <>BDC EMC /Span <>BDC EMC /Span <>BDC EMC /Span <>BDC EMC /Span <>BDC EMC /Span <>BDC EMC /Span <>BDC EMC /Span <>BDC EMC /Span <>BDC EMC /Span <>BDC EMC /Span <>BDC EMC /Span <>BDC EMC /Span <>BDC EMC /Span <>BDC EMC /Span <>BDC EMC /Artifact <>BDC q 1 0 0 1 36 224.28 cm 0.42 0.533 0.831 RG 20.7 w q 1 0 0 1 -1.45 68.75 cm 0 0 m 544.05 0 l S Q Q q 1 0 0 1 36 224.28 cm 0.839 0.843 0.91 RG 17.25 w q 1 0 0 1 -1.45 49.77 cm 0 0 m 221.7 0 l S Q Q q 1 0 0 1 36 224.28 cm 0.839 0.843 0.91 RG 17.25 w q 1 0 0 1 220.75 49.77 cm 0 0 m 321.85 0 l S Q Q q 1 0 0 1 36 224.28 cm 1 1 1 RG 38.27 w q 1 0 0 1 -1.45 21.51 cm 0 0 m 221.7 0 l S Q Q q 1 0 0 1 36 224.28 cm 0.929 0.953 0.996 RG 38.4 w q 1 0 0 1 220.5 21.57 cm 0 0 m 322.1 0 l S Q Q q 1 0 0 1 36 224.28 cm 0.863 0.863 0.863 RG q 1 0 0 1 -1.45 1.5 cm 0 0 m 544.05 0 l S Q Q EMC /Span <>BDC Q BT 0 0 0 rg /TT0 14 Tf 36 641.83 Td (LAKE SUPERIOR STATE UNIVERSI)Tj /C2_0 14 Tf 234.917 0 Td <0037003C>Tj /TT0 14 Tf ( )Tj -234.917 -16.1 Td (007004176)Tj /C2_0 14 Tf 70.075 0 Td <000300100003>Tj /TT0 14 Tf (0001 )Tj -70.075 -16.1 Td (Dental Coverage )Tj 0 -16.1 TD [(Effective Date: )-8.786 ( On or after )-13.429 (January 2025 )]TJ 0 -16.1 TD (Benefits-at-a-glance )Tj /TT1 8 Tf 0 -26.76 TD (This is intended as an easy-to-read summary and provides only a general \ overview of your benefits. It is not a contract. Additional limitations \ and )Tj 0 -9.2 TD (exclusions may apply. Payment amounts are based on BCBSM's approved amou\ nt, less any applicable deductible and/or copay. For a complete )Tj 0 -9.2 TD (description of benefits please see the applicable BCBSM certificates and\ riders, if your group is underwritten. If your group is self-funded, pl\ ease )Tj T* (see any other plan documents your group uses. If there is a discrepancy \ between this Benefits-at-a-Glance and any applicable plan document, the \ )Tj 0 -9.2 TD (plan document will control. )Tj /TT0 8 Tf 0 -18.4 TD (Coverage determination:)Tj /TT1 8 Tf 0.072 Tw 94.242 0 Td ( )Tj 0 Tw 2.295 0 Td (Claims are subject to dental necessity verification and availability of \ dental benefits when they are processed, as well as )Tj -96.537 -9.2 Td (the terms and conditions of the applicable BCBSM certificates and riders\ . )Tj /TT0 8 Tf 0 -18.4 TD (Dentist information )Tj /TT1 8 Tf 0 -9.2 TD (With Blue Dental PPO, you can choose any licensed dentist anywhere. Howe\ ver, you'll get the best coverage and save the most money when you )Tj 0 -9.2 TD (choose a Tier 1 PPO $in-network$ dentist. )Tj 0 -18.39 TD (You have outstanding access to thousands of Tier 1 PPO dentists across t\ he country through the Blue Dental PPO network. Tier 1 PPO dentists )Tj 0 -9.2 TD (agree to accept our PPO approved amount as full payment for covered serv\ ices, so you'll pay your applicable coinsurance and deductible )Tj 0 -9.2 TD (amounts. To find a Tier 1 PPO dentist near you, log into your member acc\ ount at )Tj /TT0 8 Tf 288.373 0 Td (bcbsm.com)Tj /TT1 8 Tf 0.026 Tw 44.457 0 Td ( )Tj 0 Tw 2.248 0 Td (or call )Tj /TT0 8 Tf 23.593 0 Td (1-888-826-8152. )Tj /TT1 8 Tf -358.671 -18.4 Td (If you go to a non-PPO dentist, you can still save money by choosing a T\ ier 2 participating non-PPO $out-of-network$ dentist. Tier 2 dentists \ )Tj T* (participate with us on a "per claim" basis through our Blue Par Select $\ BPS$ arrangement. They accept our BPS approved amount as full payment )Tj 0 -9.2 TD (for covered services, so you'll pay your applicable coinsurance and dedu\ ctible amounts. To find a Tier 2 participating non-PPO dentist near you,\ )Tj 0 -9.2 TD (log into your member account at )Tj /TT0 8 Tf 116.578 0 Td (bcbsm.com)Tj /TT1 8 Tf 44.457 0 Td (. 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through the end of the calend\ ar year in )Tj EMC /Span <>BDC T* (which they turn age 26, provided all eligibility requirements are met. )Tj EMC ET /Artifact <>BDC q 1 0 0 1 36 224.28 cm 1 1 1 RG 2 J q 1 0 0 1 220.5 58.4 cm 0 0 m 0 -56.02 l S Q Q q 1 0 0 1 36 224.28 cm 1 1 1 RG 2 J q 1 0 0 1 542.85 79.1 cm 0 0 m 0 -78.1 l S Q Q q 1 0 0 1 36 224.28 cm 1 1 1 RG 2 J q 1 0 0 1 -1.2 40.9 cm 0 0 m 543.55 0 l S Q Q q 1 0 0 1 36 224.28 cm 1 1 1 RG 2 J q 1 0 0 1 -1.2 2.13 cm 0 0 m 543.55 0 l S Q Q EMC /Artifact <>BDC q 1 0 0 1 36 87.75 cm 0.42 0.533 0.831 RG 20.7 w q 1 0 0 1 -1.45 112.75 cm 0 0 m 544.05 0 l S Q Q q 1 0 0 1 36 87.75 cm 0.839 0.843 0.91 RG 17.25 w q 1 0 0 1 -1.45 93.78 cm 0 0 m 221.7 0 l S Q Q q 1 0 0 1 36 87.75 cm 0.839 0.843 0.91 RG 17.25 w q 1 0 0 1 220.75 93.78 cm 0 0 m 321.85 0 l S Q Q q 1 0 0 1 36 87.75 cm 1 1 1 RG 13.2 w q 1 0 0 1 -1.45 78.06 cm 0 0 m 221.7 0 l S Q Q q 1 0 0 1 36 87.75 cm 0.929 0.953 0.996 RG 13.32 w q 1 0 0 1 220.5 78.12 cm 0 0 m 322.1 0 l S Q Q q 1 0 0 1 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