Poly Flow

<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>Poly Flow</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>Poly Flow</B></div> <bR> <div> <B>Option I</B></div> <div> <B>Preferred</B></div> <div> <TABLE BORDER="0" CELLPADDING="2" CELLSPACING="1" WIDTH="656" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="VOID" RULES="NONE" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=TOP COLSPAN=3 HEIGHT= 57 WIDTH="642"><div> <B>GROUP # 10023C</B></div> <div> <B>SUMMARY OF DENTAL BENEFITS</B></div> <bR> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 36 WIDTH="426"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="36" ALIGN="bottom" WIDTH="426" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=TOP><NOBR><div> <B>Preferred</B></div> <div> <B>In Network </B></div> </NOBR></tD> <tD VALIGN=TOP><NOBR><bR> <div> <B>Out of Network</B></div> </NOBR></tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 19 WIDTH="426"><div> <B>PREVENTIVE SERVICES</B></div> </tD> <tD VALIGN=TOP WIDTH="85"><div> <B>50%</B></div> </tD> <tD VALIGN=TOP WIDTH="129"><div> <B>50%</B></div> </tD> </tR> <tR> <tD VALIGN=TOP COLSPAN=3 HEIGHT= 16 WIDTH="642"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="16" ALIGN="bottom" WIDTH="642" HSPACE="0" VSPACE="0"></tD> </tR> <tR> <tD VALIGN=TOP COLSPAN=3 HEIGHT= 70 ><NOBR><div> EXAMS- twice per benefit year</div> <div> X-RAYS - bitewings twice per benefit year, full mouth series once every 36-month period</div> <div> CLEANINGS - twice per benefit year</div> <div> TOPICAL APPLICATION OF FLUORIDE - only for children under 19 twice per benefit year</div> </NOBR></tD> </tR> <tR> <tD VALIGN=TOP COLSPAN=3 HEIGHT= 16 WIDTH="642"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="16" ALIGN="bottom" WIDTH="642" HSPACE="0" VSPACE="0"></tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 19 WIDTH="426"><div> <B>BASIC SERVICES</B></div> </tD> <tD VALIGN=TOP WIDTH="85"><div> <B>50%</B></div> </tD> <tD VALIGN=TOP WIDTH="129"><div> <B>50%</B></div> </tD> </tR> <tR> <tD VALIGN=TOP COLSPAN=3 HEIGHT= 16 WIDTH="642"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="16" ALIGN="bottom" WIDTH="642" HSPACE="0" VSPACE="0"></tD> </tR> <tR> <tD VALIGN=TOP COLSPAN=3 HEIGHT= 143 WIDTH="642"><div> EMERGENCY PALLIATIVE</div> <div> RESTORATIVE - amalgam, composite resin, plastic restorations, and stainless steel crowns</div> <div> GENERAL ANESTHESIA - general anesthesia and IV sedation when administered by a dentist for a covered oral surgery procedure</div> <div> ENDODONTICS - treatment of root pulp, root canal</div> <div> PERIODONTICS - treatment of gums and bones supporting teeth. Periodontal cleaning</div> <div> ORAL SURGERY - extractions and other surgical dental procedures (includes pre- and post operative care)</div> </tD> </tR> <tR> <tD VALIGN=TOP COLSPAN=3 HEIGHT= 16 WIDTH="642"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="16" ALIGN="bottom" WIDTH="642" HSPACE="0" VSPACE="0"></tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 19 WIDTH="426"><div> <B>MAJOR SERVICES</B></div> </tD> <tD VALIGN=TOP WIDTH="85"><div> <B>50%</B></div> </tD> <tD VALIGN=TOP WIDTH="129"><div> <B>50%</B></div> </tD> </tR> <tR> <tD VALIGN=TOP COLSPAN=3 HEIGHT= 16 WIDTH="642"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="16" ALIGN="bottom" WIDTH="642" HSPACE="0" VSPACE="0"></tD> </tR> <tR> <tD VALIGN=TOP COLSPAN=3 HEIGHT= 87 WIDTH="642"><div> CROWNS AND CAST RESTORATIONS - only when teeth cannot be restored with amalgam, composite resin, or plastic fillings</div> <div> PROSTHODONTICS - procedures to construct or repair fixed bridges, partial or complete dentures</div> <bR> <div> <B>THERE IS NO WAITING PERIOD FOR MAJOR SERVICES.</B></div> </tD> </tR> <tR> <tD VALIGN=TOP COLSPAN=3 HEIGHT= 16 WIDTH="642"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="16" ALIGN="bottom" WIDTH="642" HSPACE="0" VSPACE="0"></tD> </tR> <tR> <tD VALIGN=TOP COLSPAN=3 HEIGHT= 47 ><NOBR><div> <TABLE BORDER="0" CELLPADDING="2" CELLSPACING="1" WIDTH="656" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="VOID" RULES="NONE" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=TOP HEIGHT= 19 WIDTH="426"><div> <B>ORTHODONTICS</B></div> </tD> <tD VALIGN=TOP WIDTH="85"><div> <B>50%</B></div> </tD> <tD VALIGN=TOP WIDTH="129"><div> <B>50%</B></div> </tD> </tR> </TABLE></div> <bR> </NOBR></tD> </tR> <tR> <tD VALIGN=TOP COLSPAN=3 HEIGHT= 82 WIDTH="642"><div> This is a summary of the Poly Flow dental benefit plan.  All benefits are subject to the contract limitations and exclusions.  For a more detailed description of benefits please refer to your Certificate of Coverage Handbook.  With the DentalSource In Network Option, DentalSource pays for Dental Services based on the Preferred Provider Schedule of Fees.  Out of network fees are based upon predetermined Usual, Customary, and Reasonable Charges.</div> </tD> </tR> <tR> <tD VALIGN=TOP COLSPAN=3 HEIGHT= 16 WIDTH="642"><div> <B>DEDUCTIBLE</B></div> </tD> </tR> <tR> <tD VALIGN=TOP COLSPAN=3 HEIGHT= 38 WIDTH="642"><div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">$0 individual</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">$0 family</div> </tD> </tR> <tR> <tD VALIGN=TOP COLSPAN=3 HEIGHT= 16 WIDTH="642"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="16" ALIGN="bottom" WIDTH="642" HSPACE="0" VSPACE="0"></tD> </tR> <tR> <tD VALIGN=TOP COLSPAN=3 HEIGHT= 20 WIDTH="642"><div> <B>MAXIMUM</B></div> </tD> </tR> <tR> <tD VALIGN=TOP COLSPAN=3 HEIGHT= 131 WIDTH="642"><div> <B>$1,000 per employee an d a combined family maximum of $2,000 per plan year.</B>  The $2,000 family maximum is shared among the entire family.  This maximum is also shared in full or part with orthodontic coverage annually.  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 plan year basis.  <B><U>Calendar Year benefit Maximum to $1,000 per Employee with singel coverage.  $2,000 per Employee with family coverage which can be met by one or all Eligible Participants in the family.</U></B><B>  The Plan Maximum is combined with all option I dental procedures (including orthodontics) and the Option I vision benefit.</B></div> <bR> </tD> </tR> <tR> <tD VALIGN=TOP COLSPAN=3 HEIGHT= 16 WIDTH="642"><div> <B>CLAIM FORMS</B></div> </tD> </tR> <tR> <tD VALIGN=TOP COLSPAN=3 HEIGHT= 66 WIDTH="642"><div> DentalSource Dental Administrators will accept all American Dental Association (ADA) approved claim forms.  This would include most computer generated claim forms that most dental offices use.  Claim forms with DentalSource's pre-printed address are available at the Human Resources Department at Poly Flow.  Claim forms are also available by contacting DentalSource.</div> </tD> </tR> <tR> <tD VALIGN=TOP COLSPAN=3 HEIGHT= 16 WIDTH="642"><div> <B>PARTICIPATING DENTIST</B></div> </tD> </tR> <tR> <tD VALIGN=TOP COLSPAN=3 HEIGHT= 49 WIDTH="642"><div> A current PPO PARTICIPATING DENTIST LIST is available at the Human Resources Department at Poly Flow.  Participating dentists have agreed to file claim forms directly with DentalSource.  Participating PPO dentists have approved fees that provide maximum dental saving.  You may use any licensed dentist in or out of network. </div> </tD> </tR> <tR> <tD VALIGN=TOP COLSPAN=3 HEIGHT= 16 WIDTH="642"><div> <B>PRE-TREATMENT ESTIMATE (PRE-DETERMINATION)</B></div> </tD> </tR> <tR> <tD VALIGN=TOP COLSPAN=3 HEIGHT= 82 WIDTH="642"><div> When the expected cost of a proposed course of treatment is $200.00 or more, the covered person's dentist must send us a treatment plan before they begin.  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 contract coverage.</div> </tD> </tR> <tR> <tD VALIGN=TOP COLSPAN=3 HEIGHT= 16 WIDTH="642"><div> <B>LIMITATIONS & EXCLUSIONS</B></div> </tD> </tR> <tR> <tD VALIGN=TOP COLSPAN=3 HEIGHT= 33 WIDTH="642"><div> Prophylaxis limited to twice per benefit year.  Fluoride limited to persons under 19 years of age.  Sealants limited to the unrestored permanent molars of covered persons under age 16.  TMJ is not covered.</div> </tD> </tR> <tR> <tD VALIGN=TOP COLSPAN=3 HEIGHT= 16 WIDTH="642"><div> <B>          MAIL CLAIMS TO:</B></div> </tD> </tR> <tR> <tD VALIGN=TOP COLSPAN=3 HEIGHT= 48 WIDTH="642"><div> <B>Dental Administrators</B></div> <div> <B>PO Box 11569</B></div> <div> <B>Albuquerque NM 87192</B></div> </tD> </tR> <tR> <tD VALIGN=TOP COLSPAN=3 HEIGHT= 16 ><NOBR><div> <B>Albuquerque Number 237-1501         Outside Albuquerque 1-888-862-8659</B></div> </NOBR></tD> </tR> </TABLE></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>