First Community Bank

<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><B><U>First Community Bank</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> </td> </tr><tr> <td valign="top" height=348 BGCOLOR="#EEEEEE" TEXT="#080000"> <div> <B>First Community Bank</B></div> <bR> <div> <TABLE BORDER="0" CELLPADDING="2" CELLSPACING="1" WIDTH="803" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="VOID" RULES="NONE" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=TOP COLSPAN=2 HEIGHT= 16 WIDTH="793"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="16" ALIGN="bottom" WIDTH="793" HSPACE="0" VSPACE="0"></tD> </tR> <tR> <tD VALIGN=TOP COLSPAN=2 HEIGHT= 57 WIDTH="793"><div> <B>GROUP # 10021</B></div> <div> <B>PREMIER PLAN</B></div> <div> <B>SUMMARY OF DENTAL BENEFITS</B></div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 16 WIDTH="698"><div> <B><U>PREVENTIVE SERVICES</U></B><B>   </B></div> </tD> <tD VALIGN=TOP><NOBR><div> <B>100% (UCR)*</B></div> </NOBR></tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 80 ><NOBR><div> EXAMS - limited to twice in each calendar year.</div> <div> X-RAYS - bitewings, twice in each calendar year period, full mouth series once every 36-month period.</div> <div> CLEANINGS - limited to twice in each calendar year.</div> <div> TOPICAL APPLICATION OF FLUORIDE - through age 18, once per calendar year.</div> <div> SEALANTS - through age 15 for permanent molars only.</div> </NOBR></tD> <tD VALIGN=TOP WIDTH="94"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="80" ALIGN="bottom" WIDTH="94" HSPACE="0" VSPACE="0"></tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 16 WIDTH="698"><div> <B><U>BASIC SERVICES</U></B></div> </tD> <tD VALIGN=TOP WIDTH="94"><div> <B>80% (UCR)*</B></div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 129 WIDTH="698"><div> <B>RESTORATIVE -</B> amalgam, composite resin, plastic restorations (fillings), and stainless steel crowns.</div> <div> <B>GENERAL ANESTHESIA</B> - general anesthesia and IV sedation when administered by a dentist for covered oral surgery procedures.</div> <div> <B>ENDODONTICS</B> - treatment of dental pulp and surgical procedures involving the root.</div> <div> <B>PERIODONTICS </B>- treatment of gums, bones supporting teeth and periodontal cleanings.</div> <div> <B>ORAL SURGERY</B> - extractions and other surgical dental procedures.  (includes pre- and post- operative care)</div> <div> <B>SPACE MAINTAINERS - </B>through age 15</div> <div> <B>EMERGENCY PALLIATIVE TREATMENT</B></div> </tD> <tD VALIGN=TOP WIDTH="94"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="129" ALIGN="bottom" WIDTH="94" HSPACE="0" VSPACE="0"></tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 16 WIDTH="698"><div> <B><U>MAJOR SERVICES</U></B></div> </tD> <tD VALIGN=TOP WIDTH="94"><div> <B>50% (UCR)*</B></div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 49 WIDTH="698"><div> <B>CROWNS AND CAST RESTORATIONS</B> - only when teeth cannot be restored with amalgam, composite resin, or plastic fillings.</div> <div> <B>PROSTHODONTICS</B> - procedures to construct or repair fixed bridges, partial or complete dentures.</div> </tD> <tD VALIGN=TOP WIDTH="94"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="49" ALIGN="bottom" WIDTH="94" HSPACE="0" VSPACE="0"></tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 16 WIDTH="698"><div> <B><U>ORTHODONTICS</U></B></div> </tD> <tD VALIGN=TOP WIDTH="94"><div> <B>50%(UCR)*</B></div> </tD> </tR> <tR> <tD VALIGN=TOP COLSPAN=2 HEIGHT= 33 WIDTH="793"><div> Treatment to correct poorly aligned teeth and jaws which significantly interferes with function.  Plan pays 50% up to a lifetime maximum of $1000.00 through age 18.  Usual, Customary and Reasonable<B> </B>fees as determined by DentalSource Administrators.</div> </tD> </tR> <tR> <tD VALIGN=TOP COLSPAN=2 HEIGHT= 16 WIDTH="793"><div> <B>DentalSource Phone Albuquerque 505 237-1501 / Toll Free 888 862-8659</B></div> </tD> </tR> <tR> <tD VALIGN=TOP COLSPAN=2 HEIGHT= 48 WIDTH="793"><div> <B>DEDUCTIBLE</B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700c800000000.png" HEIGHT="13" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">$   50 INDIVIDUAL</div> <div> <IMG BORDER="0" SRC="Symb075c00b700c800000000.png" HEIGHT="13" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">$  150 FAMILY</div> </tD> </tR> <tR> <tD VALIGN=TOP COLSPAN=2 HEIGHT= 66 WIDTH="793"><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 NOT applied to PREVENTIVE or ORTHODONTIC SERVICES. The deductible is applied to BASIC and MAJOR SERVICES. The deductible is applied on a calendar year basis. Calendar Year is January 1st to December 31st.</div> </tD> </tR> <tR> <tD VALIGN=TOP COLSPAN=2 HEIGHT= 16 WIDTH="793"><div> <B>MAXIMUM</B></div> </tD> </tR> <tR> <tD VALIGN=TOP COLSPAN=2 HEIGHT= 32 WIDTH="793"><div> <IMG BORDER="0" SRC="Symb075c00b700c800000000.png" HEIGHT="13" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">$1,000.00 PER ENROLLED PERSON - (non-orthodontic)</div> <div> <IMG BORDER="0" SRC="Symb075c00b700c800000000.png" HEIGHT="13" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">$1,000.00 lifetime for orthodontic services</div> </tD> </tR> <tR> <tD VALIGN=TOP COLSPAN=2 HEIGHT= 33 WIDTH="793"><div> The MAXIMUM is the total dollar amount that will be paid by this program toward covered dental benefits for enrolled persons. The MAXIMUM is applied on a calendar year basis. Calendar Year<B> </B>is January 1<FONT SIZE="1" COLOR="#000000" FACE="Arial" >st</FONT> to December 31st.</div> </tD> </tR> <tR> <tD VALIGN=TOP COLSPAN=2 HEIGHT= 16 WIDTH="793"><div> <B>FREEDOM OF CHOICE</B></div> </tD> </tR> <tR> <tD VALIGN=TOP COLSPAN=2 HEIGHT= 33 WIDTH="793"><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="793"><div> <B>Participating Dentists:</B></div> <div> <B>DentalSource contracted dentists will:</B></div> </tD> </tR> <tR> <tD VALIGN=TOP COLSPAN=2 HEIGHT= 81 WIDTH="793"><div> File claim forms for you. Members are responsible for signing the claim form and verifying accuracy of patient/member information.</div> <div> Accept payment directly from DentalSource. DentalSource will pay the the benefit coverage portiondirectly to the dentist. The non-covered portion is the responsibility of the member.</div> <div> Participating dentists have approved fees that provide maximum dental savings. <B>The dentist will not bill more than the allowable contracted charges</B>. This means the procedures will be paid at the percentage coverage stated on this benefit sheet.</div> </tD> </tR> <tR> <tD VALIGN=TOP COLSPAN=2 HEIGHT= 32 WIDTH="793"><div> <B>Non-Participating Dentists: </B></div> <div> <B>Non-contracted dentists:</B></div> </tD> </tR> <tR> <tD VALIGN=TOP COLSPAN=2 HEIGHT= 48 ><NOBR><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 as determined by DentalSource Inc.</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 amount paid by DentalSource.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700c800000000.png" HEIGHT="13" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Member may use any licensed Dentist.</div> </NOBR></tD> </tR> <tR> <tD VALIGN=TOP COLSPAN=2 HEIGHT= 33 WIDTH="793"><div> <B>PRE-EXISTING CONDITIONS -</B> The plan will not pay for initial prosthetic placement for congenitally missing teeth or for a tooth that has been removed before the patient is covered under the First Community Bank program.</div> </tD> </tR> <tR> <tD VALIGN=TOP COLSPAN=2 HEIGHT= 49 WIDTH="793"><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> </tD> </tR> <tR> <tD VALIGN=TOP COLSPAN=2 HEIGHT= 16 WIDTH="793"><div> <B>PRE-TREATMENT ESTIMATE (PRE-DETERMINATION)</B></div> </tD> </tR> <tR> <tD VALIGN=TOP COLSPAN=2 HEIGHT= 49 WIDTH="793"><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 ensure 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> </tD> </tR> <tR> <tD VALIGN=TOP COLSPAN=2 HEIGHT= 33 WIDTH="793"><div> <B>ELIGIBILITY - </B>You, your spouse or domestic partner and your unmarried dependent children to age 25 are eligible as defined by your First Community Bank Group Contract.</div> </tD> </tR> <tR> <tD VALIGN=TOP COLSPAN=2 HEIGHT= 33 WIDTH="793"><div> 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.</div> </tD> </tR> <tR> <tD VALIGN=TOP COLSPAN=2 HEIGHT= 16 WIDTH="793"><div> <B>DentalSource Phone Albuquerque 505 237-1501 / Toll Free 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>PREMIER PROVIDERS</U></B></FONT></A></div> <bR> <div> <A HREF="preferred_provider_list.htm" TARGET="_top" TITLE="Preferred Provider List"><FONT COLOR="#FF0000"><B><U>PREFERRED PROVIDERS</U></B></FONT></A></div> <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>