PREMIER PLAN GROUP # 10018 SUMMARY OF DENTAL BENEFITS
PREVENTIVE SERVICES	100% (UCR)*
EXAMS - limited to two per contract year. X-RAYS - bitewings, twice per contract year, full mouth series once every 60-month period. CLEANINGS - limited to two per contract year. EMERGENCY PALLIATIVE TOPICAL APPLICATION OF FLUORIDE - through age 18, twice per contract year. SPACE MAINTAINERS - through age 15. SEALANTS - through age 15, for permanent molars only.
BASIC SERVICES	80% (UCR)*
RESTORATIVE - amalgam, composite resin, plastic restorations (fillings), and stainless steel crowns. GENERAL ANESTHESIA - general anesthesia and IV sedation when administered by a dentist for a covered oral surgery procedure. ENDODONTICS - treatment of dental pulp and surgical procedure involving the root. PERIODONTICS - treatment of gums and bones supporting teeth. ORAL SURGERY - extractions and other surgical dental procedures. (includes pre- and post operative care)
MAJOR SERVICES	50% (UCR)*
CROWNS AND CAST RESTORATIONS - only when teeth cannot be restored with amalgam, composite resin, or plastic fillings. PROSTHODONTICS - procedures to construct or repair fixed bridges, partial or complete dentures.
ORTHODONTICS	No Benefit
* Usual, Customary and Reasonable fees as determined by DentalSource Administrators in  conjunction with Chaves County.
DEDUCTIBLE
$  25 INDIVIDUAL $  75 FAMILY 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 NOT applied to PREVENTIVE SERVICES. The deductible is applied to BASIC and MAJOR SERVICES. The deductible is applied on a contract year basis. Contract Year is July 1st to June 30th.
MAXIMUM
$1,000.00 PER ENROLLED PERSON
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 contract year basis. Contract Year is July 1st to June 30th.
FREEDOM OF CHOICE
You choose the dentist - worldwide. You may visit a specialist without referrals. You may change your dentist without notifying DentalSource Administrators.
You choose the benefit:
Participating Dentists: DentalSource contracted dentists will: File claim forms for you. Members are responsible for signing the claim form and verifying accuracy of patient/member information. 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. Participating dentists have approved fees that provide maximum dental savings. 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.
Non-Participating Dentists:    Non-contracted dentists:
Member pays the dentist directly for all services rendered. Member files claims directly to DentalSource Administrators. Member will receive reimbursement for the allowable amount as determined by DentalSource Inc. Member is responsible for any charge over the allowable.
PRE-EXISTING CONDITIONS - are a covered benefit as long as treatment has NOT been started prior to your eligible date.
OPTIONAL SERVICES - 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.
PRE-TREATMENT ESTIMATE (PRE-DETERMINATION)
It is STRONGLY suggested that you get a pre-treatment estimate of benefits for all MAJOR SERVICES. 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.
ELIGIBILITY - You, your spouse, and your dependent children to age 25 are eligible as defined by your Chaves County Group Contract.
This summary of the group dental program is subject to the provisions of the group dental contract and cannot modify or affect the group dental contract in any way, nor shall you accrue any rights because of any statement in or omission from this summary.