Buy Up

<body topmargin=0 leftmargin=0 marginheight=0 marginwidth=0> <table cellpadding=0 cellspacing=0 border=0><tr> <td valign="top" height=100 style=" border-bottom: 1px solid #CCCCCC;" BGCOLOR="#FFFFFF" TEXT="#080000" bgproperties="fixed" background="3d77b6e1egerdp.jpg"> <div> <IMG SRC="3d5e1580.jpg" border=0 width="225" height="88" ALIGN="LEFT" HSPACE="0" VSPACE="0"></div> <bR> <div> <A HREF="index.htm" TARGET="_top" TITLE="DentalSource"><FONT COLOR="#990000"><B><U>Home</U></B></FONT></A><B><U>   I   </U></B><A HREF="core_plan.htm" TARGET="_top" TITLE="Core Plan"><FONT COLOR="#990000"><B><U>Core Plan</U></B></FONT></A><B><U>   |   </U></B><B><U>Buy Up</U></B><B><U>   |   </U></B><A HREF="contact_us.htm" TARGET="_top" TITLE="Contact Us"><FONT COLOR="#990000"><B><U>Contact Us</U></B></FONT></A></div> <div> </div> </td> </tr><tr> <td valign="top" height=348 BGCOLOR="#EEEEEE" TEXT="#080000"> <div> <B>Buy Up</B></div> <div> <IMG SRC="436dc540.gif" border=0 width="220" height="84" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></div> <div> <B>PREMIER</B></div> <div> <B>GROUP # 10011B</B></div> <div> <B>SUMMARY OF DENTAL BENEFITS</B></div> <bR> <div> <TABLE BORDER="0" CELLPADDING="2" CELLSPACING="1" WIDTH="717" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="VOID" RULES="NONE" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=TOP HEIGHT= 16 WIDTH="579"><div> <B>PREVENTIVE SERVICES</B></div> </tD> <tD VALIGN=TOP WIDTH="127"><div> 100% (UCR)*</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 161 WIDTH="579"><bR> <div> EXAMS - twice per calendar year X-RAYS - bitewings, twice per calendar year, full mouth series once every 3 years CLEANINGS - twice per calendar year EMERGENCY PALLIATIVE</div> <bR> <div> TOPICAL APPLICATION OF FLUORIDE - twice per calendar year, for Children up to 15</div> <bR> <div> SPACE MAINTAINERS</div> <bR> <div> SEALANTS- Up to age 15</div> <bR> </tD> <tD VALIGN=TOP WIDTH="127"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="161" ALIGN="bottom" WIDTH="127" HSPACE="0" VSPACE="0"></tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 16 WIDTH="579"><div> <B>BASIC SERVICES</B></div> </tD> <tD VALIGN=TOP WIDTH="127"><div> 80% (UCR)*</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 209 WIDTH="579"><bR> <div> RESTORATIVE - amalgam, composite resin, plastic restorations, and stainless steel crowns</div> <bR> <div> GENERAL ANESTHESIA - general anesthesia and IV sedation when administered by a dentist for a covered oral surgery procedure</div> <bR> <div> ENDODONTICS - treatment of root pulp, root canal</div> <bR> <div> PERIODONTICS - treatment of gums and bones supporting teeth</div> <bR> <div> ORAL SURGERY - extractions and other surgical dental procedures (includes pre- and post operative care)</div> <bR> </tD> <tD VALIGN=TOP WIDTH="127"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="209" ALIGN="bottom" WIDTH="127" HSPACE="0" VSPACE="0"></tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 18 WIDTH="579"><div> <B>MAJOR SERVICES</B></div> </tD> <tD VALIGN=TOP WIDTH="127"><div> 80% (UCR)*</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 97 WIDTH="579"><bR> <div> CROWNS AND CAST RESTORATIONS - only when teeth cannot be restored with amalgam, composite resin, or plastic restorations</div> <bR> <div> PROSTHODONTICS - procedures to construct or repair fixed bridges partial or complete dentures</div> <bR> </tD> <tD VALIGN=TOP WIDTH="127"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="97" ALIGN="bottom" WIDTH="127" HSPACE="0" VSPACE="0"></tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 16 WIDTH="579"><div> <B>ORTHODONTICS</B></div> </tD> <tD VALIGN=TOP WIDTH="127"><div> 50% (UCR)*</div> </tD> </tR> <tR> <tD VALIGN=TOP COLSPAN=2 HEIGHT= 81 WIDTH="707"><div> <IMG BORDER="0" SRC="Symb075c00b700c800000000.png" HEIGHT="13" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">$50.00 Lifetime Deductible</div> <div> <IMG BORDER="0" SRC="Symb075c00b700c800000000.png" HEIGHT="13" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">$2,000 Lifetime Maximum</div> <bR> <div> Procedures using appliances to treat poor alignment of teeth and/or jaws which significantly interferes with their function.  Orthodontic coverage up to age 19.</div> </tD> </tR> <tR> <tD VALIGN=TOP COLSPAN=2 HEIGHT= 49 WIDTH="707"><bR> <div> <B>* Usual, Customary and Reasonable </B>fees as determined by DentalSource Administrators in  conjunction with St. Vincent Hospital.</div> </tD> </tR> <tR> <tD VALIGN=TOP COLSPAN=2 HEIGHT= 65 WIDTH="707"><bR> <div> <B>This is a summary of the St. Vincent Hospital dental benefit plan.  All benefits are subject to the contract limitations and exclusions.  For a more detailed description, please refer to your Summary Plan Description Handbook.</B></div> </tD> </tR> <tR> <tD VALIGN=TOP COLSPAN=2 HEIGHT= 48 WIDTH="707"><bR> <div> <B>DEDUCTIBLE</B></div> <bR> </tD> </tR> <tR> <tD VALIGN=TOP COLSPAN=2 HEIGHT= 48 WIDTH="707"><div> <B><IMG BORDER="0" SRC="Symb075c00b700c800000000.png" HEIGHT="13" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">   </B>$ 50 INDIVIDUAL</div> <div> <IMG BORDER="0" SRC="Symb075c00b700c800000000.png" HEIGHT="13" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">   $150 FAMILY</div> <div> <IMG BORDER="0" SRC="Symb075c00b700c800000000.png" HEIGHT="13" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">   $ 50 <B>orthodontic lifetime</B> deductible per person</div> </tD> </tR> <tR> <tD VALIGN=TOP COLSPAN=2 HEIGHT= 65 WIDTH="707"><bR> <div> The DEDUCTIBLE is the amount of money that each enrolled person must pay before benefits will be paid under this program for covered dental benefits for BASIC and MAJOR SERVICES. The deductible is <B>NOT </B>applied to PREVENTIVE SERVICES.  The deductible is applied to BASIC and MAJOR SERVICES. The deductible is applied on a plan year basis.</div> </tD> </tR> <tR> <tD VALIGN=TOP COLSPAN=2 HEIGHT= 48 WIDTH="707"><bR> <div> <B>MAXIMUM</B></div> <bR> </tD> </tR> <tR> <tD VALIGN=TOP COLSPAN=2 HEIGHT= 97 WIDTH="707"><div> <B><IMG BORDER="0" SRC="Symb075c00b700c800000000.png" HEIGHT="13" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">$2,000.00 PER ENROLLED PERSON (non-orthodontic)</B></div> <bR> <div> The MAXIMUM is the total dollar amount that will be paid by this program towards covered dental benefits for enrolled persons. The MAXIMUM is applied on a calendar year basis for all dentistry except orthodontics. </div> <bR> <div> <B><IMG BORDER="0" SRC="Symb075c00b700c800000000.png" HEIGHT="13" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">$2,000.00 </B><B><U>LIFETIME</U></B><B> MAXIMUM</B> <B>for ORTHODONTIC SERVICES</B></div> </tD> </tR> <tR> <tD VALIGN=TOP COLSPAN=2 HEIGHT= 32 WIDTH="707"><bR> <div> <B>FREEDOM OF CHOICE</B></div> </tD> </tR> <tR> <tD VALIGN=TOP COLSPAN=2 HEIGHT= 49 WIDTH="707"><bR> <div> <B>You choose the dentist </B>- worldwide.<B> </B>You may visit a specialist without referrals. You may change your dentist without notifying DentalSource Administrators.</div> </tD> </tR> <tR> <tD VALIGN=TOP COLSPAN=2 HEIGHT= 32 WIDTH="707"><bR> <div> <B>You choose the benefit:</B></div> </tD> </tR> <tR> <tD VALIGN=TOP COLSPAN=2 HEIGHT= 306 WIDTH="707"><div> <B>Participating Dentists:</B></div> <bR> <div> <IMG BORDER="0" SRC="Symb075c00b700c800000000.png" HEIGHT="13" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">DentalSource contracted dentists will:</div> <div> <IMG BORDER="0" SRC="Symb075c00b700c800000000.png" HEIGHT="13" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">File claim forms for you. Members are responsible for signing the claim form and verifying accuracy of patient/member information.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700c800000000.png" HEIGHT="13" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Accept payment directly from DentalSource. DentalSource will pay the the benefit coverage portion directly to the dentist. The non-covered portion is the responsibility of the member.</div> <bR> <div> Participating dentists have approved fees that provide maximum dental saving. The dentist will not bill more than the allowable contracted charges. This means the procedures will be paid at the percentage coverage stated on this benefit sheet.</div> <bR> <div> <B>Non-Participating Dentists:   </B></div> <div> <B>Non-contracted dentists:</B></div> <bR> <div> <IMG BORDER="0" SRC="Symb075c00b700c800000000.png" HEIGHT="13" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Member pays the dentist directly for all services rendered.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700c800000000.png" HEIGHT="13" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Member files claims directly to DentalSource Administrators.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700c800000000.png" HEIGHT="13" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Member will receive reimbursement for the allowable amount based on Usual, Customary, and Reasonable</div> <div>        (UCR) fees as determined by DentalSource.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700c800000000.png" HEIGHT="13" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Member is responsible for any charge over the allowable.</div> </tD> </tR> <tR> <tD VALIGN=TOP COLSPAN=2 HEIGHT= 81 WIDTH="707"><bR> <div> <B>OPTIONAL SERVICES - </B>DentalSource allows the least expensive American Dental Association (ADA) accepted treatment. For example: DentalSource allows and pays for silver (amalgam) fillings on posterior teeth. If you choose a composite resin, you will pay for the difference in price.</div> <bR> </tD> </tR> <tR> <tD VALIGN=TOP COLSPAN=2 HEIGHT= 32 WIDTH="707"><div> <B>PRE-TREATMENT ESTIMATE (PRE-DETERMINATION)</B></div> <bR> </tD> </tR> <tR> <tD VALIGN=TOP COLSPAN=2 HEIGHT= 82 WIDTH="707"><div> It is <B>STRONGLY </B>suggested that you get a pre-treatment estimate of benefits for all <B>MAJOR SERVICES. </B>A Pre-Treatment estimate will insure that you know the procedure you are contemplating having done is covered under this benefit plan as well as what your financial responsibility will be. A pre-treatment estimate is not a determination of the need for treatment, only a determination of contracted coverage.</div> <bR> </tD> </tR> <tR> <tD VALIGN=TOP COLSPAN=2 HEIGHT= 33 WIDTH="707"><div> <B>ELIGIBILITY - </B>You, your spouse, and your unmarried dependent children to age 25 are eligible as defined by your St. Vincent Hospital Group Contract.</div> </tD> </tR> <tR> <tD VALIGN=TOP COLSPAN=2 HEIGHT= 16 WIDTH="707"><div> <B>SEND DENTAL CLAIMS TO</B>:</div> </tD> </tR> <tR> <tD VALIGN=TOP COLSPAN=2 HEIGHT= 64 WIDTH="707"><div> <B>DENTALSOURCE</B></div> <div> <B>P.O. Box 11569</B></div> <div> <B>Albuquerque, NM 87192</B></div> <div> <B>505 237-1501 or 1-888-862-8659</B></div> </tD> </tR> </TABLE></div> <bR> <div> <A HREF="premier_provider_list.htm" TARGET="_top" TITLE="Premier Provider List"><FONT COLOR="#FF0000"><B><U>PROVIDER LIST</U></B></FONT></A></div> <bR> <bR> <bR> </td> </tr><tr> <td valign="top" height=31 style=" border-top: 1px solid #CCCCCC;" BGCOLOR="#FFFFFF" TEXT="#080000"> <div> <B>Please Visit our Alternative Health Care Web Site at</B> <FONT SIZE="2" COLOR="#FF0033" FACE="Arial" ><A HREF="http://www.benefitsource.org" TARGET="_top" TITLE="http://www.benefitsource.org"><B><U>www.benefitsource.org</U></B></A></FONT></div> <bR> </td> </tr></table></body>