Benefits for Scheduled Plan

Schedule of Benefits (what the dental plan will pay) - Over 400 Covered Procedures

*Sample Schedule of Benefits - How much the insurance will pay*	Economy Plan	Value Plan	Standard Plan
Plan Maximum	$750	$750	$750
Preventive - NO DEDUCTIBLE
Two evaluations per benefit period	$8 (each)	$12 (each)	$16 (each)
Two cleanings per benefit period (Age 14 and over)	$20 (each)	$30 (each)	$40 (each)
Two cleanings per benefit period (Under age 14)	$14 (each)	$20 (each)	$27 (each)
One topical fluoride treatment in conjunction with prophylaxis for children age 18 and under per benefit period	$8	$11	$15
Basic
X-ray -- Complete series (including bitewings)	$24	$36	$48
Bitewing x-rays (2 films) twice in a benefit period	$9	$13	$18
Amalgam restoration (silver fillings)—one surface, primary or permanent	$21	$32	$42
Extraction, erupted tooth or exposed root	$24	$36	$48
Surgical removal of tooth (completely bony)	$50	$75	$100
Deep sedation/general anesthesia	$70	$105	$140
Major
Maxillary partial denture—resin base	$150	$225	$300
Denture repair—repair broken base	$18	$27	$36
Endodontics—root canal, anterior	$80	$120	$160
Periodontal scaling and root planning, limited (per quadrant). Each quadrant is eligible for consideration once in a 2 year period	$26	$39	$52
Crown—full cast noble metal	$112	$168	$224
Crown repair	$30	$45	$60
Pontics—porcelain fused to noble metal	$112	$168	$224

Dental Maximum Per Person, Per Calendar year at Any Dentist You Choose

ü Economy Plan $750 per calendar year

ü Value Plan $750 Per calendar year

ü Standard Plan $750 per calendar year

Dental Deductible Per Person

ü $50 Calendar Year-Per Person

ü Applies to Basic & Major Services only

Elimination Period

ü 12 month waiting period on major procedures

Vision Benefit at VSP Providers with No Deductible

ü 100% coverage for one routine vision exam for each insured per calendar year

ü 20% discount off a complete pair of frames and lenses

ü 15% discount off contact lens services

ü An average discount of 10-25% off laser vision correction surgery for PRK or

LASIK at a VSP provider

ü There are over 29,000 providers in the United States

* Please refer to your certificate for complete details on all benefits, frequencies, and plan

limitations. A certificate will be mailed after your enrollment form has been processed.

Limitations

Covered Expenses will not include and no benefit will be payable for expenses incurred:

for Major Procedures in the first twelve months that a person is insured.
for any procedure except exams, cleaning and fluoride applications for the first 12 months when an insured or dependent becomes classified as a late entrant. If an insured or dependent does not enroll within 31 days from the date the person qualifies for the insurance or who elected to become insured again after canceling a premium contribution agreement will be classified as a late entrant.
for any treatment which is for cosmetic purposes. Facings on crowns or pontics behind the second bicuspid are considered cosmetic.
to replace any prosthetic appliance, crown, inlay or onlay restoration, or fixed partial denture within five years of the date of the last placement of these items. However, if a replacement is required because on an accidental bodily injury sustained while the person is insured, it will be a Covered Expense.
for initial placement of any prosthetic appliance of fixed partial denture unless such placement is needed because of the extraction of one or more natural teeth while a person is insured. The extraction of a third molar (wisdom tooth) will not qualify. Any such appliance or fixed partial denture must include the replacement of the extracted tooth or teeth.
for any procedure started before a person becomes insured.
for any procedure which began after a person’s insurance terminates; or for any prosthetic dental appliances installed or delivered more than 90 days after a person’s insurance terminates.
to replace lost or stolen appliances.
for appliances, restorations, or procedures to:

alter vertical dimension;
restore or maintain occlusion;
splint or replace tooth structure lost because of abrasion or attrition; or
treat disturbances of the temporomandibular joint (T.M.J.). (except in the states of Alabama, Florida, Minnesota, Mississippi, and Washington)

for any procedure which is not shown on the List of Dental Procedures provided with your Certificate of Insurance.
for education or training in, and supplies used for, dietary or nutritional counseling, personal oral hygiene or dental plaque control.
for the completion of claim forms.
for orthodontic treatment.
because of any injury arising out of, or in the course of, work for wage or profit.
by a person because of a sickness for which he or she is eligible for benefits under any Worker’s Compensation act or similar law.
for charges for which a person is not liable or which would not have been made had no insurance been in force.
for services which are not recommended by a physician or which are not required for necessary care and treatment.
because of war or any act of war, declared or not.
by a person if payment is not legal where the person is living when expenses are incurred.
for sealants which are:

not applied to a permanent molar,
applied after attaining age 17,
reapplied to a molar within 3-years from the date of a previous sealant application.

subgingival curettage or root planning (procedure numbers 4220 and 4341) unless the presence of periodontal disease is confirmed by both radiographs and pocket depth summaries of each tooth involved.