All Dental Options (Limitations and Provision May Apply) EAA Access ePPO In Network Only Highlights Preventive Diagnostic; Preventive See Fee Schedule Approximately 2,200 Access dentists All dentists accept new patients Family members may choose different dentists $2000 Calendar Year Maximum per member $25 deductible/member; $75 deductible/family on basic and major services No claim forms No pre-existing condition exclusions Implants are covered No referrals needed to see Specialists Fee Schedule plan Basic Basic restorative Simple tooth extractions Prosthetic maintenance General anesthesia for covered surgical procedures Palliative emergency dental care See Fee Schedule Major Major restorative Prosthodontics Periodontic Endodontic Oral Surgery Endosteal Implants (in lieu of 3-unit bridge) See Fee Schedule Ortho Deductible (Calendar Year) Annual Maximum (Calendar Year) Dependents Full Time Students Ortho Select is available for $49. See brochure for details. $25/$75 on basic and major $2,000 Age 19 Age 23 For additional Access ePPO information, please refer to your fee schedule booklets. IDENTIFICATION CARDS Two identification cards from DentaQuest will be mailed to your home shortly after your enrollment. Both cards are issued in the subscriber’s name, but can be used by everyone covered under your plan. CHOOSING A DENTIST You’ll enjoy great benefits when you receive your dental care from one of the PPO network dentists, including; Lower out-of-pocket costs: Participating dentists agree to accept reduced fees for their services. Since your co-payments are based on these fees, you pay lower out-of-pocket costs than you would if you went to an out-of-network dentist. No claims processing: Participating dentists will prepare and submit claims for you. Direct payment: DentaQuest pays the dentist directly, so you don’t have to pay the covered amount up front and wait for a reimbursement check. To find out if your dentist is part of the DentaQuest PPO network, check the PPO Directory of Participating Dentists, visit our website at www.dentaquestdental.com, or call our Customer Service Department at 1-800-334-6277. THE CLAIMS PROCESS FOR IN-NETWORK DENTISTS Present your ID card to the dentist at the time of your visit. The dentist will submit your claim to DentaQuest. DentaQuest will send you an Explanation of Benefits (EOB) detailing what DentaQuest paid the dentist under your plan’s coverage and the remaining patient balance, which you pay directly to the dentist. You are responsible for any co-payments and deductibles. If you receive treatment that is not covered under your plan, you may be billed at the dentist’s usual fee rather than DentaQuest’s negotiated fee. The same is true if you continue to receive services once you have reached your annul maximum. COORDINATION OF BENEFITS If your family is covered by more than one dental plan (or a medical plan that offers dental coverage), DentaQuest will coordinate benefits with the other carrier. In determining coverage, total payments from both carriers cannot exceed the allowable charge for service. If you have a question about Coordination of Benefits (COB), please contact our Customer Service Department at 1-800-334-6277. OTHER CLAIMS INFORMATION All Claims must be submitted within 90 days from the date of service. Ask your dentist to submit a “pre-treatment estimate” to DentaQuest for any procedure that exceeds $600. This will enable us to help you estimate any out-of-pocket expenses you may incur. Under your plan’s subrogation clause, you may be required to reimburse DentaQuest for claim payments if you also receive payment from a third party who is held liable for an injury that required the dental care. WHERE TO GET MORE INFORMATION If you have further questions, please contact DentaQuest’s Customer Service Department at 1-800-334-6277, or visit our website at www.dentaquestdental.com. Note: This material is a guide to your dental benefits. Limitations and exclusions may apply. If any question arises about the benefits described here, or if any information is not covered, the terms of the subscriber certificate will govern in all cases. Copies of the subscriber’s certificate are available through your benefits administrator.