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					                         Best Buy Dental & Vision
                                                                                            Dental and Vision Coverage
                                                                                                   in One Plan*
                                                                                            For Individuals, Small Employers,
                                                                                             Retirees, and Senior Citizens




                                                                                                       Dental Underwritten by:




                                                                                                       Vision Administered by:




STNDLIFE 06-06
POL-DENT (10/05)
*Dental Insurance Policy benefits and Vision Coverage are provided through a combination of policies
Dental Insurance Policy Benefits
Two plans to choose from: Indemnity or DPO
• Free choice of dentist                                  • Benefits increase after the first and second years
• In- and Out-of-Network benefits                          • Benefits up to $1200 per calendar year
• 6 month waiting period basic                            •12 month waiting period for oral surgery and major



                     Plan Pays   Plan Pays    Plan Pays
Your Deductible                                                                                     Services Covered
                      1st Year   2nd Year     3rd Year
  $50 per person       80%         90%          100%          Type 1 - Diagnostic and Preventive Treatment
 per calendar year                                            Diagnostic: Routine periodic examinations once in a 6 month period.
for Types 1, 2 and                                            Preventive: Dental prophylaxis (teeth cleaning and scaling) once in
   3 procedures.                                              a 6 month period (including application of topical fluoride for dependent children only).
                                                              Radiography: Bitewing x-rays once in a 6 month period. Full mouth x-rays one in a 36
                                                              month period.
   See above           60%         70%           80%          Type 2 - Basic Procedures (6 month waiting period)
                                                              Restorative: Amalgam, synthetic porcelain or plastic fillings.
                                                              Other: Space maintainers, recementation of crowns.
   See above             0%        40%           50%          Type 3 - Major Procedures (12 month waiting period)
                                                              Endodontics: Pulpal therapy and root canals.
                                                              Periodontics: Treatment of diseases of the gums.
                                                              Prosthetics: Gold restorations, crowns, bridges, partials and complete dentures.
                                                              Other: Pontics, repair of crowns and bridges, repair of full and partial dentures.
                                                              Oral Surgery: Extractions and other oral surgery.




    Indemnity Plan benefits are based on Usual,                                     DPO Plan benefits in or out of network are based on
     Customary & Reasonable Charges (UCR).                                         the negotiated provider fee schedule. Locate Dental
              Choose any Dentist.                                                    Providers in your area at www.mwgdental.com.

                                      Monthly Dental & Vision Rates
               Indemnity Plan Rates                                                                       DPO Plan Rates
 Area          Member            Plus One              Family                        Area           Member               Plus One              Family
   1            $35.81             $64.87              $93.93                           1            $29.20               $51.97                   $74.75
   2            $39.12             $71.31              $103.51                          2            $31.77               $57.00                   $82.22
   3            $42.79             $81.47              $114.15                          3            $34.64               $62.58                   $90.53
   4            $46.86             $86.42              $125.97                          4            $37.82               $68.78                   $99.74
   5            $51.38             $95.23              $139.08                          5            $41.34               $75.66               $109.97
   6            $56.41            $105.02              $153.63                          6            $45.26               $83.29               $121.32
   7            $61.98            $115.88              $169.79                          7            $52.46               $91.76               $133.92
        Includes: $4.00 Billing Fee, $1.00 Association Dues                                  Includes: $4.00 Billing Fee, $1.00 Association Dues
                      and Basic Vision Rates                                                               and Basic Vision Rates



                                     Online Enrollment: www.BestBuyDental.com
The Basic Vision Plan by Spectera
Quality and Affordability
Frames: You receive the best value (cost and quality) from your vision care program when you choose frames from the Basic Vision Plan selection.
All frames on the market today are offered with preferred pricing at private practice providers, and are offered at a discount at retail providers. Popular
styles are available for the whole family, including metal, plastic, and titanium. *Call or check website below.

Lenses: Lenses include all powers and sizes, and are provided by leading national labs, contracted to quality and service standards.

Preferred pricing is available on all lens materials, styles, and options, offering important vision benefits, such as progressives, anti-reflective and UV
coatings, tints, and more.

Special Savings
Laser Vision Correction: Receive access to a 15 percent discount or five percent off any promotional price for laser vision correction surgery through
the Laser Vision Network of America. The network is comprised of more than 300 laser vision correction specialists nationwide.

To find a participating laser vision provider, visit www.spectera.com and click on the Laser Surgeon Locator link, or call 1.877.28.SIGHT (toll-free).

                                                                                                                                             1
                                                                                                                                 You Pay
 Vision Exam                                                                                                                     Paid-in-full after $20 office visit copay
         2
 Frames                                              Covered-in-full frames                                                      Preferred pricing:
 At private practice providers                          Quality Collection frame                                                     $60
                                                        Elite Collection frame                                                       $85
                                                     Non-Collection frames                                                       15% discount
 At retail chain providers                           Members receive a discount                                                  Discount
                    3
 Standard Lenses                                                                                                                 Preferred pricing:
                                                     Single vision lenses                                                        $45
                                                     Bifocal lenses                                                              $65
                                                     Trifocal lenses                                                             $95
 Contact Lenses                                      Fitting, follow-up, and materials                                           20% discount
                                                     Contact lenses (non-disposable)                                             20% discount
                                                     Contact lenses (disposable)                                                 Member pays full provider-billed charges
                                                     Access to mail-order contact lenses                                         5% discount
 Refractive Eye Surgery                              Members receive access to discounted refractive eye
                                                     surgery procedures


There is no limit on purchases of eyeglasses and contacts at preferred pricing.
1. Preferred pricing is only available at network provider locations. Please consult your vision care provider for preferred pricing on additional lens styles (i.e. progressive lenses), materials, and
options (i.e. coatings, tints, etc.). For more information, call member services or visit www.spectera.com.
2. Members receive preferred pricing on frames at network private practice providers, and a discount at network retail chains. Discounts are off of network providers’ billed charges; the discount
is 15% for all frames not included in the covered-in-full selection.
3. Standard lenses: non-aspheric, glass/plastic (CR39), clear, all powers, all sizes, standard scratch-resistant coating. Lower prices on Standard lenses and contacts will apply at some retail locations.



         *To locate a network provider near you, call toll-free 800.839.3242
                            or visit www.spectera.com
                                       Spectera, Inc. administers vision benefits underwritten by the following entities: United HealthCare Insurance Company,
                                   United HealthCare Insurance Company of New York, Unimerica Insurance Co., Inc., and American General Assurance Company.




Benefits Association
As a member of Benefits Association you receive the following Benefits and Services:
Discount prescription program • Pre-Employment Background Reports • Customized Web Services • Office Supplies
Vitamins & Nutritional Supplements • Auto Rental Discounts • Quest Travel PlanGlobal Long Distance Services
Best Buy Dental & Vision Dental Price Areas
Indemnity Plan                                         DPO Plan
    States                Zip Code              Area       States                Zip Code              Area
     Alaska                 995-996              7          Alaska                 995-996              5
                           All Others            6                                All Others            4
     Arizona              864, 856-865           2          Arizona              864, 856-865           2
                           All Others            1                                All Others            1
    Arkansas                   All               1         Arkansas                   All               1
    California         900-905, 915-918,         7
                            956-958              4         California         900-905, 915-918,         7
                   906-914, 919-927, 930-939,    6                                 956-958              4
                     949, 952-955, 959-961       6                        906-914, 919-927, 930-939,    6
                           All Others            5                          949, 952-955, 959-961       6
                                                                                  All Others            5
    Colorado              803, 808-810           4
                           All Others            1         Colorado              803, 808-810           4
   Connecticut              068-069              6                                All Others            1
                           All Others            5        Connecticut              068-069              6
    Delaware                   All               2                                All Others            5
     Florida                320-322              4         Delaware                   All               2
                            330-334              5          Florida                320-322              4
                           All Others            3                                 330-334              5
     Georgia                300-303              2                                All Others            3
                           All Others            3          Georgia                300-303              1
     Illinois               600-605              2                                All Others            2
                            606-608              3          Illinois               600-605              2
                           All Others            1                                 606-608              2
     Indiana                463-464              3                                All Others            1
                               473               2
                           All Others            1          Indiana                463-464              2
                                                                                  All Others            1
      Iowa                     All               1
     Kansas                 660-662              2           Iowa                     All               1
                           All Others            1          Kansas                 660-662              2
    Kentucky                   All               1                                All Others            1
    Louisiana                  712               3         Kentucky                   All               2
                            707-711              2         Louisiana                  712               3
                           All Others            1                                 707-711              2
    Michigan           480-483, 490-491          2                                All Others            1
                            488-489              3         Michigan           480-483, 490-491          2
                           All Others            1                                48 8-489              3
   Minnesota                   554               3                                All Others            1
                          530-553, 555           2
                           All Others            1        Minnesota                   554               3
   Mississippi              390-392              2                               530-553, 555           2
                           All Others            1                                All Others            1
     Missouri          640-641, 644-648          2        Mississippi              390-392              2
                           All Others            1                                All Others            1
    Nebraska                   All               1          Missouri          640-641, 644-648          2
   New Mexico                  881               2                                All Others            1
                               882               5         Nebraska                   All               1
                           All Others            1        New Mexico                  881               2
     Nevada                 893-898              5                                    882               5
                           All Others            4                                All Others            1
  North Carolina          277, 287-289           2          Nevada                 893-898              5
                               286               3                                All Others            4
                           All Others            1
      Ohio             430-436, 439-445          2       North Carolina          277, 287-289           4
                          450-452, 456           2                                    286               5
                           All Others            1                                All Others            3
                                                             Ohio             430-436, 439-445          1
    Oklahoma           730-731, 740-741          2                               450-452, 456           1
                          All Others             1                                All Others            1
  Pennsylvania         170-178, 182-187          3         Oklahoma           730-731, 740-741          2
                           190-192               4                                All Others            1
                          All Others             2
                                                         Pennsylvania         170-178, 182-187          3
  South Carolina              All                1                                 190-192              4
    Tennessee          370-374, 380-384          2                                All Others            2
                          All Others             1
                                                         South Carolina               All               2
      Texas                  754                 4
                                                           Tennessee          370-374, 380-384          2
                           750-753               3                                All Others            1
                      756, 757, 776, 777         1           Texas                    754               4
                         All Others              2                                 750-753              3
                                                                              756, 757, 776, 777        1
     Virginia            201, 220-221            5                                All Others            2
                           222-223               6
                       224-225, 230-232          1          Virginia             201, 220-221           5
                       228-229, 240-244          2                                 222-223              6
                          All Others             4                            224-225, 230-232          1
  West Virginia        255-257, 262-265          2                            228-229, 240-244          2
                          All Others             1                                All Others            4
    Wyoming                   All                1       West Virginia        255-257, 262-265          2
                                                                                  All Others            1
                                                           Wyoming                    All               1
Dental Exclusions
EXCLUSIONS AND LIMITATIONS (*may vary by state.)                                    and andontia (congenitally missing teeth), except those services pro-
Limitations on all Benefits – Optional Services:                                    vided to newborn children for congenital defect or birth abnormalities or
                                                                                    services that may be provided under Orthodontic Benefits.
Services that are more expensive than the form of treatment customarily
                                                                                 c) Services for restoring tooth structure lost from wear, erosion, or abrasion,
provided under accepted dental practice standards are called "Optional
                                                                                    for rebuilding or maintaining chewing surfaces due to teeth out of align-
Services." Optional Services also include the use of specialized techniques
                                                                                    ment or occlusion, or for stabilizing the teeth. Such services include, but
instead of standard procedures. For example:
                                                                                    are not limited to: equilibration, periodontal splinting, occlusal adjust-
(a) a crown where a filling would restore the tooth;                                ment.
(b) a precision denture/partial where a standard denture/partial could be
                                                                                 d) Any Single Procedure started prior to the date the person became cov-
used;
                                                                                    ered for such services under this program.
(c) an inlay/onlay instead of an amalgam restoration;
     or                                                                          e) Prescribed drugs, medication or analgesia.
(d) a composite/resin restoration instead of an amalgam restoration on poste-    f) Experimental procedures.
rior teeth.                                                                      g) Charges by any hospital or other surgical or treatment facility and any
If you receive Optional Services, your Benefits will be based on the lower          additional fees charged by the Dentist for treatment in any such facility.
cost of the customary service or standard practice instead of the higher cost    h) Charges for anesthesia, other than by a licensed Dentist for administer-
of the Optional Service. You will be responsible for the difference between         ing general anesthesia in connection with covered oral surgery services.
the higher cost of the Optional Service and the lower cost of the customary      i) Extra oral grafts (grafting of tissues from outside the mouth to oral tis-
service or standard practice.                                                       sues).
                                                                                 j) Services with respect to any disturbance of the temporomandibular joint
EXCLUSIONS (*Exclusions may vary by state.)                                         (jaw joint).
Standard Life does not pay Benefits for:
                                                                                 k) Services performed by any person other than a Dentist or auxiliary per-
a) Services for injuries or conditions which are compensable under work-            sonnel legally authorized to perform services under the direct supervi-
    ers' compensation or employers' liability laws; services which are pro-         sion of a Dentist.
    vided to the Enrollee by any federal or state government agency or are
                                                                                 l) Replacement of teeth extracted prior to the member’s effective date.
    provided without cost to the Enrollee by any municipality, county or
    other political subdivision except as such exclusion may be prohibited       m) Replacement of any Crown, Jacket, Cast Restoration, Bridge or Denture
    by law.                                                                         that the patient received in the previous five (5) years.
b) Services with respect to congenital (hereditary) or developmental (fol-       The preceding information is a brief description of coverage. See policy
    lowing birth) malformations or cosmetic surgery or dentistry for purely      POL-DENT (10/05) for complete details.
    cosmetic reasons, including but not limited to cleft palate, maxillary and
    mandibular (upper and lower jaw) malformations, enamel hypoplasia
    (lack of development), fluorosis (a type of discoloration) of the teeth,

				
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