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Optional Dental Benefits by jizhen1947

VIEWS: 6 PAGES: 12

									Optional Dental Benefits
       For Employees
    Table of Contents




                  Table of Contents

                  Participation Requirements/Enrollment Procedures  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 3

                  Eligibility Requirements  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 4

                  AccessPlus Dental 100 Dental Discount Program Summary  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 5
                          by First Dental Health

                  Dental Plan 3000 Prepaid Benefit Summary  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 6
                          by SmileSaverSM

                  Dental Plan 1000 Prepaid Benefit Summary  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 7
                          by SmileSaverSM

                  Dental Plan 3000 and 1000 Exclusions & Limitations  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 8

                  Dental Plan EPO 3500, PPO 4000 & 5000 Benefit Summaries                                                                                               .  .  .  .  .  .  .  .  .  .  .  .  .  . 9
                          by Ameritas Group

                  Dental Plan EPO 3500, PPO 4000 & 5000 Exclusions & Limitations  .  .  .  .  .  .  .  . 11




                                                 This guide explains the various dental
                                                 benefit designs that are available through
                                                 CaliforniaChoice 51+.

                                                 Please ask your health plan administrator which
                                                 plans are available at your company.




2
                                                                            Participation Requirements/Enrollment Procedures




Participation Requirements
    AccessPlus Dental 100
    n   You and any eligible dependents have to be enrolled for medical coverage through the
        CaliforniaChoice 51+ Program .
    n   You are responsible for the reduced fees that apply to listed services .

    Prepaid Dental Plans 3000 & 1000, EPO Plan 3500 and PPO Dental Plans 4000 & 5000
    n   These benefit designs must be offered through your company
    n   You will be responsible for any supplemental premiums, as well as member copays that apply to listed services .


Enrollment Procedures
     1 . Ask your health plan administrator for a list of available plans .
     2 . Complete the Dental Coverage Section of your enrollment application .
     3 . Return the completed application to your health plan administrator .


*Does not qualify as comparable dental coverage and will not count toward prior credit.




                                                                                                                               3
    Eligibility Requirements



           Eligibility Requirements
           To qualify for dental coverage in the Prepaid Dental Plan 3000, 1000, EPO 3500, PPO 4000 & 5000 through
           CaliforniaChoice 51+, the following conditions must be met:

           Employee
              1. Employees must work the minimum number of hours required to be considered eligible for benefits as
                 determined by the employer. (Employees working less than 30 hours per week, as well as inactive owners,
                 contracted (1099), temporary, employees eligible for health care coverage offered by or through a labor union,
                 seasonal or substitute workers are not eligible).
              2. You have to be employed by your company for a pre-established length of time or waiting period.
                 (If you are enrolled and have a spouse and/or children, they may also qualify for coverage under your plan.)

           Dependents
                SPOUSE must be legally married to you in order to be eligible.
                CHILDREN may include children born to you, a step-child or legal ward of, or adopted by eligible employee,
                employee spouse or domestic partner.
              For Dental Plan 3000 & 1000
                Dependent children under the age of 26.
              For Dental Plan 3500, 4000 and 5000
                Unmarried dependent children under the age of 19, or unmarried dependent children under age 25 who are
                full-time students at a qualified college, university, vocational, or secondary school.
                You are not required to extend coverage to your spouse or dependent children. To decline coverage on their
                behalf, you must complete and sign the waiver section of the enrollment application.
                Enrollment for spouse and children is contingent upon employee enrollment. The dependent makeup for
                dental and medical coverage must be the same. However, if your dependents are not enrolled in medical, any
                dependent makeup for dental is acceptable.

           Domestic Partner Coverage
                At time of employee eligibility for enrollment, the employee and partner must fall into all of the following
                categories:
                   n   Share a common residence
                   n   Neither is married under either statutory, common law or part of another domestic partnership
                   n   Both be 18 years of age or older
                   n   Share an intimate and committed relationship
                   n   Agree to be jointly responsible for each others basic living expenses incurred during the domestic relationship
                   n   Both be mentally competent
                   n
                      Not related by blood to a degree of closeness that would prohibit marriage in this state
                   n   Agree to notify CaliforniaChoice 51+ immediately upon termination of domestic partnership
                Members who are in a same sex partnership or are over the age of 62 are required to submit a state-stamped Certificate of
                Registration of Domestic Partnership from a state or local government agency authorized to perform such registrations within 30 days
                of issue; all others must submit a signed Affidavit of Domestic Partnership.




4
                                                                                                                                                    Dental Discount Program Summary



AccessPlus Dental 100 by First Dental Health
The AccessPlus Dental 100 is a discount program available, at no additional cost, to employers who are not
currently offering dental coverage to employees. Employees and dependents who wish to take advantage of the
AccessPlus Dental 100 program must also be enrolled for medical coverage through the CaliforniaChoice 51+
program. This plan offers dental services at reduced fees through a network of over 12,000 dentists and specialists
without prior authorization.

                       Dental Services                                                                                 Your Cost                                          Average
                                                                             Region I               Region II              Region III             Region IV    Region V    Cost*
           Exams & Diagnostics
           Initial Oral Exam                                                  $     38                $     38               $     50                $   48    $   68      $   92
           Periodic Oral Exam                                                 $     20                $     20               $     22                $   22    $   36      $   52
           X-Rays – Periapical First Film                                     $     19                $     19               $     21                $   20    $   27      $   30
           X-Rays – Bite-Wing (4 films)                                       $     32                $     31               $     39                $   37    $   60      $   67
           Preventive
           Adult Teeth Cleaning                                               $     70                $     70               $     83                $   76    $   95      $ 97
           Child Teeth Cleaning (under age 16)                                $     44                $     43               $     52                $   47    $   66      $ 67
           Oral Surgery
           Removal of Uncomplicated Single Tooth                              $ 82                    $ 79                   $   111                 $ 94      $   149     $   161
           Removal of Impacted Tooth – Partially Bony                         $ 271                   $ 272                  $   393                 $ 386     $   406     $   448
           Removal of Impacted Tooth – Completely Bony                        $ 348                   $ 348                  $   507                 $ 492     $   479     $   526
           Surgical Removal - Erupted Tooth                                   $ 147                   $ 146                  $   204                 $ 201     $   245     $   269
           Restorative (Cavities)
           Amalgam
              1 Surface, Permanent Tooth                                      $     70                $     67               $ 84                    $ 82      $ 131       $ 147
              2 Surfaces, Permanent Tooth                                     $     92                $     88               $ 111                   $ 109     $ 169       $ 190
           Resin Based Composite
              1 Surface, Anterior Tooth                                       $ 95                    $ 94                   $ 111                   $ 103     $ 155       $ 159
              2 Surfaces, Anterior Tooth                                      $ 114                   $ 112                  $ 131                   $ 121     $ 198       $ 213
           Endodontics
           Single Root Canal                                                  $ 492                   $ 477                  $ 604                   $ 504     $ 715       $ 613
           Bi-root Canal                                                      $ 583                   $ 561                  $ 718                   $ 598     $ 875       $ 903
           Molar Root Canal                                                   $ 849                   $ 845                  $1,012                  $ 986     $1,128      $1,166
           Periodontics
           Gingivectomy – Per Tooth                                           $ 121                   $ 118                  $ 129                   $ 129     $ 298       $ 354
           Periodontal Scaling & Root Planing (quadrant)                      $ 93                    $ 92                   $ 113                   $ 108     $ 134       $ 244
           Crowns — Single Restoration
           Porcelain – Base Metal (posterior)                                 $   658                 $   625                $   748                 $   708   $ 933       $ 972
           Full Cast Noble Metal                                              $   670                 $   634                $   739                 $   718   $ 889       $ 972
           Resin (indirect)                                                   $   240                 $   240                $   240                 $   240   $ 678       $ 418
           Porcelain – High Noble Metal                                       $   763                 $   763                $   894                 $   868   $1,002      $1,044
           Orthodontics
           Children (maximum age 18)                                          $3,973                  $3,973                 $4,580                  $4,580    $4,580      N/A
           Adult                                                              $3,973                  $3,973                 $4,580                  $4,580    $4,580      N/A
           Prosthodontics
           Complete Upper or Lower Denture                                    $ 925                   $ 898                  $1,195                  $1,160    $1,413      $1,576
           Partial Upper or Lower Denture                                     $ 549                   $ 469                  $ 653                   $ 604     $1,193      $1,330

       Discounts are available throughout California when using an AccessPlus Dental 100 provider. *Average costs based on 2008 Medical Data Research.



To determine copays, select the region/county where services are received:
Region I: Los Angeles, Orange, and Ventura
Region II: Imperial, Riverside, San Bernardino, San Diego
Region III: Alameda, Contra Costa, Napa, San Benito, San Francisco, San Luis Obispo, San Mateo, Santa Barbara, Santa Clara, Santa Cruz, Solano, Marin
(94300-94921, 94924-94925, 94929-94930, 94932-94950, 94956-94971, 94973-94974, 94976-94998)
Region IV: Butte, El Dorado, Fresno, Kern, Kings, Madera, Mendocino, Merced, Monterey, Nevada, Placer, Sacramento, San Joaquin, Shasta, Siskiyou,
Sonoma, Stanislaus, Sutter, Tehama, Tulare, Tuolumne, Yolo, Marin (94951-94955)
Region V: Alpine, Amador, Calaveras, Colusa, Del Norte, Glenn, Humboldt, Inyo, Lake, Lassen, Mariposa, Modoc, Mono, Plumas, Sierra, Trinity, Yuba




                                                                                                                                                                                      5
    Dental Plan 3000 Prepaid Benefit Summary



          Dental Plan 3000 by SmileSaverSM - Prepaid Dental Plan
          This is a summary of benefits for the Dental Plan 3000, a prepaid dental plan offered through CaliforniaChoice 51+ . To be eligible,
          your employer must be located within the plan service area shown below . If you are enrolled in the Dental Plan 3000, you need to
          choose a participating dentist from the SmileSaverSM network (You can look up a dentist through the Online Provider Directory at
          www.calchoiceplus.com) . These dentists will provide dental care for you and any dependents who are enrolled in the plan .

                                                                                                                               Summary of Benefits and Member Copays
          Office Visits                                                                                                                                         Crowns*
          During regular hours  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . No charge               Crown - porcelain with metal (anterior) .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . $                                  120 .00
          Emergency office visit (After regular hours )  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .$ 30 .00                                        Crown - porcelain with metal (posterior)  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . $                                   225 .00
                                                                                                                                                                Crown - full cast metal  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . $             115 .00
          Diagnostic                                                                                                                                            Crown - stainless steel (primary or permanent)  .  .  .  .  .  .  .  .  .  .  .  .  .  . $                                                40 .00
          Comprehensive oral exam  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .                      No charge
          Periodic oral exam  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .         No charge      Endodontics
          Oral hygiene instruction  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .               No charge      Single root canal therapy (anterior)  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . $ 100 .00
          X-rays, complete series  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .             No charge      Bi-root canal (bicuspid)  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . $ 135 .00
          Bitewing X-rays  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .   No charge      Molar root canal  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . $ 185 .00

          Preventive                                                                                                                                            Dentures and Partials
          Teeth cleaning - adult (1 every 6 months)  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . No charge                                             Complete upper or lower denture  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . $ 120 .00
          Teeth cleaning - child (1 every 6 months) .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . No charge                                           Immediate upper or lower denture  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . $ 175 .00
                                                                                                                                                                Partial upper or lower, acrylic base (including
          Restorative                                                                                                                                           conventional clasps and rests)  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . $ 110 .00
          Amalgam Restorations Primary teeth -
              Cavities - 1 surface  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .$ 9 .00                 Oral Surgery (extractions)
              Cavities - 2 surfaces  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .$ 14 .00                  Single tooth  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . $    10 .00
              Cavities - 3 surfaces  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .$ 22 .00                  Each additional tooth  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . $             10 .00
              Cavities - 4 or more surfaces  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .$ 25 .00                            Surgical removal of erupted tooth .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . $                             25 .00
          Amalgam Restorations Permanent teeth -                                                                                                                Soft tissue impaction  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . $             35 .00
              Cavities - 1 surface  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .$ 9 .00                 Partial bony impaction  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . $               50 .00
              Cavities - 2 surfaces  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .$ 14 .00
              Cavities - 3 surfaces  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .$ 22 .00                  Orthodontics**
              Cavities - 4 or more surfaces  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .$ 25 .00                            Orthodontics - adult
          Resin Restorations Permanent teeth -                                                                                                                  full upper and lower banded case  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .$1,950 .00
              Composite resin - 1 surface, anterior tooth  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .$ 25 .00                                               Orthodontics - child (Up to age 19)
              Composite resin - 2 surfaces, anterior tooth  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .$ 35 .00                                                 full upper and lower banded case  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .$1,600 .00
              Composite resin - 1 surface, posterior tooth  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .$ 60 .00
              Composite resin - 2 surfaces, posterior tooth .  .  .  .  .  .  .  .  .  .  .  .  .  .  .$ 85 .00                                                  * Cost of high noble metal (gold, etc .) may be charged extra when used . Not to
                                                                                                                                                                   exceed actual laboratory cost of metal .
          Periodontics                                                                                                                                          ** 24 month treatment
          Gingivectomy/gingivoplasty, per quadrant .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .$ 85 .00
          Periodontal scaling/root planing - per quadrant  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .$ 26 .00



          Prepaid Dental Plan 3000 Service Area
                                                                                                                      And within the following zip codes in these counties:
               Dental coverage is available                                                                           Amador:                                Madera:                                               San Benito:                                               Stanislaus:
               throughout these counties:                                                                             95654                                  93637, 93638                                          95023, 95024, 95043,                                      95307, 95319, 95328,
                                                                                                                                                             Mariposa:                                             95045                                                     95350, 95352, 95353,
                                                                                                                      Butte:
               Alameda                                       San Bernardino                                                                                  95338                                                                                                           95354, 95355, 95356,
                                                                                                                      95914, 95917, 95948                                                                          Shasta:
               Contra Costa                                  San Diego                                                                                                                                                                                                       95361, 95367, 95368,
                                                                                                                                                             Mendocino:                                            96001, 96002, 96003,                                      95380, 95381, 95384
               Fresno                                                                                                 Colusa:
                                                             San Francisco                                                                                   95427, 95482                                          96007, 96019, 96022,
                                                                                                                      95950                                                                                        96033, 96047, 96062,                                      Sutter:
               Imperial                                      San Joaquin
                                                                                                                      El Dorado:                             Merced:                                               96073, 96079, 96087,                                      95659, 95668, 95674,
               Kern                                          San Luis Obispo
                                                                                                                      95630, 95667, 95682                    95301, 95303, 95312,                                  96089, 96095                                              95676, 95953, 95957,
               Los Angeles                                   San Mateo                                                                                       95315, 95317, 95333,                                                                                            95982, 95991
               Marin                                                                                                  Humboldt:                              95334, 95339, 95340,                                  Solano:
                                                             Santa Barbara
                                                                                                                      95501, 95502, 95521,                   95341, 95342, 95343,                                  94510, 94533, 94535,                                      Yolo:
               Monterey                                      Santa Clara
                                                                                                                      95525, 95534, 95536,                   95344, 95348, 95365                                   94585, 94589, 94590,                                      95605, 95616, 95691,
               Napa                                          Santa Cruz                                                                                                                                            94591, 95620, 95687,                                      95695
                                                                                                                      95537, 95540, 95547,
               Orange                                        Sonoma                                                                                          Placer:                                               95688
                                                                                                                      95549, 95550, 95551,                                                                                                                                   Yuba:
               Riverside                                                                                              95556                                  95603, 95616, 95650,
                                                             Tulare                                                                                                                                                                                                          95369, 95692, 95901,
                                                                                                                                                             95661, 95677, 95678,
               Sacramento                                    Ventura                                                  Kings:                                 96145                                                                                                           95918, 95919, 95961
                                                                                                                      93230, 93291




6
                                                                                                                                                                              Dental Plan 1000 Prepaid Benefit Summary



Dental Plan 1000 by SmileSaverSM - Prepaid Dental Plan
This is a summary of benefits for the Dental Plan 1000, a prepaid dental plan offered through CaliforniaChoice 51+ . To be eligible,
your employer must be located within the plan service area shown below . If you are enrolled in the Dental Plan 1000, you need to
choose a participating dentist from the SmileSaverSM network (You can look up a dentist through the Online Provider Directory at
www.calchoiceplus.com) . These dentists will provide dental care for you and any dependents who are enrolled in the plan .

                                                                                                                     Summary of Benefits and Member Copays
Office Visits                                                                                                                                         Crowns*
During regular hours  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . No charge                  Crown - porcelain with metal (anterior) .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .$ 70 .00
Emergency office visit (After regular hours )  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .$ 20 .00                                        Crown - porcelain with metal (posterior)  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .$ 175 .00
Broken appointment (Without 24 hour notice)  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .$ 20 .00                                                Crown - full cast metal  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .$ 60 .00
                                                                                                                                                      Crown - stainless steel (primary or permanent)  .  .  .  .  .  .  .  .  .  .  .  .  .  . No charge
Diagnostic
Comprehensive oral exam  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .                      No charge      Endodontics
Periodic oral exam  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .         No charge      Single root canal therapy (anterior)  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . $ 40 .00
Oral hygiene instruction  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .               No charge      Bi-root canal (bicuspid)  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . $ 65 .00
X-rays, complete series  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .             No charge      Molar root canal  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . $ 95 .00
Bitewing X-rays  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .   No charge
                                                                                                                                                      Dentures and Partials
Preventive                                                                                                                                            Complete upper or lower denture (each)  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .$ 70 .00
Teeth cleaning - adult (1 every 6 months)  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . No charge                                             Immediate upper or lower denture (each) .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .$ 120 .00
Teeth cleaning - child (1 every 6 months) .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . No charge                                           Partial upper or lower, acrylic base (including
                                                                                                                                                      conventional clasps and rests) (each)  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .$ 50 .00
Restorative
Amalgam Restorations Primary teeth                                                                                                                    Oral Surgery (extractions)
    Cavities - 1 surface  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . No charge                    Single tooth  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .   No charge
    Cavities - 2 surfaces  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . No charge                      Each additional tooth  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .               No charge
    Cavities - 3, 4 or more surfaces  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . No charge                                   Surgical removal of erupted tooth .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .                               No charge
Amalgam Restorations Permanent teeth                                                                                                                  Soft tissue impaction  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .               No charge
    Cavities - 1 surface  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . No charge                    Partial bony impaction  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .                 No charge
    Cavities - 2 surfaces  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . No charge
    Cavities - 3, 4 or more surfaces  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . No charge                                   Orthodontics**
Resin Restorations Permanent teeth                                                                                                                    Orthodontics - adult
    Composite resin - 1 surface, anterior tooth  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .$ 10 .00                                               full upper and lower banded case  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .$1,950 .00
    Composite resin - 2 or 3 surfaces, anterior tooth  .  .  .  .  .  .  .  .  .  .  .  .$ 10 .00                                                     Orthodontics - child (Up to age 19)
    Composite resin - 1 surface, posterior tooth  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .$ 60 .00                                                 full upper and lower banded case  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .$1,600 .00
    Composite resin - 2 surfaces, posterior tooth .  .  .  .  .  .  .  .  .  .  .  .  .  .  .$ 85 .00
                                                                                                                                                       * Cost of high noble metal (gold, etc .) may be charged extra when used . Not to
Periodontics                                                                                                                                             exceed actual laboratory cost of metal .
Gingivectomy/gingivoplasty, per quadrant .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . No charge                                            ** 24 month treatment
Periodontal scaling/root planing - per quadrant  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .$ 20 .00




Prepaid Dental Plan 1000 Service Area
                                                                                                           And within the following zip codes in these counties:
     Dental coverage is available                                                                           Amador:                                Madera:                                                 San Benito:                                                 Stanislaus:
     throughout these counties:                                                                             95654                                  93637, 93638                                            95023, 95024, 95043,                                        95307, 95319, 95328,
                                                                                                                                                                                                           95045                                                       95350, 95352, 95353,
                                                                                                            Butte:                                 Mariposa:
     Alameda                                       San Bernardino                                                                                                                                                                                                      95354, 95355, 95356,
                                                                                                            95914, 95917, 95948                    95338                                                   Shasta:
     Contra Costa                                  San Diego                                                                                                                                                                                                           95361, 95367, 95368,
                                                                                                                                                                                                           96001, 96002, 96003,                                        95380, 95381, 95384
     Fresno                                                                                                 Colusa:                                Mendocino:
                                                   San Francisco                                                                                                                                           96007, 96019, 96022,
                                                                                                            95950                                  95427, 95482                                            96033, 96047, 96062,                                        Sutter:
     Imperial                                      San Joaquin
     Kern                                                                                                   El Dorado:                             Merced:                                                 96073, 96079, 96087,                                        95659, 95668, 95674,
                                                   San Luis Obispo
                                                                                                            95630, 95667, 95682                    95301, 95303, 95312,                                    96089, 96095                                                95676, 95953, 95957,
     Los Angeles                                   San Mateo                                                                                                                                                                                                           95982, 95991
                                                                                                                                                   95315, 95317, 95333,                                    Solano:
     Marin                                         Santa Barbara                                            Humboldt:
                                                                                                                                                   95334, 95339, 95340,                                    94510, 94533, 94535,                                        Yolo:
     Monterey                                      Santa Clara                                              95501, 95502, 95521,                   95341, 95342, 95343,
                                                                                                            95525, 95534, 95536,                                                                           94585, 94589, 94590,                                        95605, 95616, 95691,
     Napa                                          Santa Cruz                                                                                      95344, 95348, 95365                                     94591, 95620, 95687,                                        95695
                                                                                                            95537, 95540, 95547,
     Orange                                        Sonoma                                                   95549, 95550, 95551,                   Placer:                                                 95688
                                                                                                                                                                                                                                                                       Yuba:
     Riverside                                     Tulare                                                   95556                                  95603, 95616, 95650,                                                                                                95369, 95692, 95901,
     Sacramento                                    Ventura                                                                                         95661, 95677, 95678,                                                                                                95918, 95919, 95961
                                                                                                            Kings:
                                                                                                                                                   96145
                                                                                                            93230, 93291




                                                                                                                                                                                                                                                                                                            7
    Dental Plan 3000 and 1000 Exclusions & Limitations



          Dental 3000 and 1000 Exclusions & Limitations
             n   Dental treatment must be received from the Member’s participating dental office unless exception is
                 specifically authorized in writing by the Plan .
             n   Routine and periodic examinations are limited to once every 6 months per enrolled Member .
             n   Prophylaxis procedures are limited to once every 6 months .
             n   Bitewing radiographs (x-rays) in conjunction with periodic examinations are limited to one series of films in any
                 12 consecutive month period . Full mouth radiographs (x-rays) in conjunction with periodic examinations are
                 limited to once every 3 years . Panoramic films are limited to once every 3 years .
             n   Fluoride treatment is limited to enrolled Members under the age of 18 years once every 6 months .
             n   Periodontal scaling and root planing, and/or sub-gingival curettage, and periodontal maintenance procedures
                 are limited to one course of therapy during any 12 month period .

          The following dental services and procedures are not included in the Dental 3000 or 1000:
             n   Any procedure not specifically listed as a covered benefit .
             n   Dental treatment or expenses incurred in connection with any dental procedures started prior to the Member’s
                 effective date under this Plan or after termination of the Member’s coverage . Example: teeth prepared for
                 crowns, root canal treatment in progress, etc .
             n   All treatment of fractures and dislocations .
             n   Extraction for orthodontic purposes .
             n   Dental procedures and charges incurred as part of implants (placement or removal) and prosthetic devices
                 placed on implants (fixed or removable) . Example: bridges, crowns, dentures .
             n   Replacement of lost or stolen dentures, crown and bridgework or other dental appliances .
             n   Dental treatment or procedures requiring or associated with fixed prosthodontic restorations (other than those
                 for replacement of structure lost due to decay) when part of extensive oral rehabilitation or reconstruction .
             n   Diagnosis or treatment by any method of any condition related to the jaw joint, TMJ or associated musculature,
                 nerves or other tissues .
             n   A dental treatment plan, which, in the opinion of the Participating Dentist, is not medically necessary, will not
                 produce a beneficial result or has a poor prognosis .
             n   Any corrective treatment required as a result of dental services performed by a non-participating dentist
                 while this coverage is in effect and any dental services started by a non-participating dentist will not be the
                 responsibility of the participating dental office or the Plan for completion or compensation .
                                          This is a summary of Exclusions & Limitations only.
                                     For a complete listing, please see the Evidence of Coverage.




8
                                                        Dental Plan EPO 3500, PPO 4000 & 5000 Benefit Summaries



Dental EPO 3500, PPO 4000 & 5000 by Ameritas Group Benefits and Copays
This is a summary of benefits for the EPO 3500 and PPO 4000 & 5000 underwritten by Ameritas Group, a division
of Ameritas Life Insurance Corp .

                                       EPO Dental 3500                      PPO Dental 4000                       PPO Dental 5000
   Plan Benefits                  In-Network      Out-of-Network^      In-Network       Out-of-Network+      In-Network          Out-of-Network+
   Annual Maximum                   $1,000            $1,000             $1,000             $1,000             $1,500                $1,500
   Annual Deductible                  $50               $50                $50                $50                $50                   $50
   Preventive Care                Ded . waived     Ded . applies       Ded . waived      Ded . applies       Ded . waived         Ded . applies
   Preventive                        100%              100%               100%               80%                100%                  80%
   Basic                             80%               80%                80%                80%                80%                   80%
   Major* (12 mo . wait period)      50%               50%                50%                50%                50%                   50%
   Endo/Perio                        80%*              50%*               80%                50%*               80%                   50%*
   Restorative                       80%               80%                80%                80%                80%                   80%
(EPO 3500 - In-Network Providers available in California only .)
^ Out-of-Network benefits are covered at the maximum allowable or scheduled charge .
+ Out-of-Network benefits are covered at U & C .
* The following are subject to a 12 month waiting period for major services:
        n   A group without a prior comparable group dental plan
        n   Newly hired employees
   A group qualifies for a credit toward the waiting period if the following requirements are satisfied:
         n  A group has a prior comparable group dental plan with no lapse in coverage
         n  A group submits prior dental plans most recent billing statement and statement from up to 12 months prior, 24 months for
            orthodontia


Please Note:
          1 .   Employer must contribute at least 50% of the employee premium of the lowest cost dental plan being offered
          2 .   Employee participation must equal 100%, if the employer pays 100% of the employee premium
          3 .   All new hires are subject to the waiting periods for major and orthodontia
          4 .   All groups without comparable dental coverage are subject to the waiting periods for major and orthodontia




Dental RewardsSM by Ameritas Group
Members who visit the dentist and use only a portion of their annual maximum benefit in a year are rewarded with
additional benefits for the following year . Based on the plan selected, members can earn additional money toward
their next year’s annual maximum benefit – if they use less than half of the annual maximum, they can increase
their next year’s coverage by $250 and earn an additional $100 to $150 if they visit a network provider . For more
information on Dental RewardsSM, please visit www.ameritasgroup.com . (Dental RewardsSM is a registered service
mark of Ameritas Life Insurance Corp . and is used with permission .)

                                                    Plan 3500                         Plan 4000                             Plan 5000
    Carry Over Amount                                  $250                               $250                                $250
    PPO Bonus                                          $100                               $100                                $150
    Benefit Threshold                                  $500                               $500                                $750
    Maximum Carry Over Amount                         $ 1,000                           $ 1,000                              $ 1,000


                                                  For orthodontia, please see next page




                                                                                                                                                   9
     Dental Plan EPO 3500, PPO 4000 & 5000 Benefit Summaries



           Dental EPO 3500, PPO 4000 & 5000 by Ameritas Group
           Benefits and Copays - Orthodontia
           Orthodontia is an employer optional benefit selected for the entire group.
               Optional Orthodontia*                         Plan 3500                             Plan 4000                        Plan 5000
                                                   In Network       Out-of-network       In Network       Out-of-network   In Network    Out-of-network
             Orthodontia (24 mo . wait period)**      50%                50%                50%                50%           50%                50%
             Annual Maximum                           None               None               None               None          None               None
             Lifetime Maximum                       $ 1,000            $ 1,000            $ 1,000            $ 1,000        $ 1,000         $ 1,000

            * Orthodontia benefits are available to children only . Treatment must begin prior to their 19th birthday .
           ** The following are subject to a 24 month waiting period for orthodontia services:
                  n   A group without a prior comparable group dental plan
                  n   Newly hired employees


           A group qualifies for credit towards the waiting period if the following requirements are satisfied:
                  n    Group has a prior comparable group dental plan with no lapse in coverage
                  n    Group submits prior dental plans most recent billing statement and statement from up to 24 months prior




10
                                     Dental Plan EPO 3500, PPO 4000 & 5000 Exclusions & Limitations



EPO 3500, PPO 4000 & 5000 Exclusions & Limitations

  No benefits will be paid for expenses incurred:
  n   For overdentures and associated procedures .              n   For a condition covered under any Workers’
  n   For charges in excess of those considered reasonable          Compensation Act or similar law .
      and customary .                                           n   That are applied toward satisfying a deductible .
  n   For cosmetic procedures .                                 n   That are generally considered by the dental
  n   For the replacement of dentures, bridge inlays, onlays        profession as experimental or investigational .
      or crowns that can be repaired or restored to normal      n   For the treatment of cleft palate and anodontia .
      function .                                                n   For services or supplies payable under any
  n   For implants and:                                             medical expense plan .
        n Replacement of lost or stolen appliances              n   For orthodontia, unless included within
        n Replacement of retainers                                  Coverage Schedule .
        n Athletic mouthguards
                                                                n   Prior to the date the insured is covered under
        n Precision or semi-precision attachments
                                                                    the policy .
        n Dental duplication or sealants
                                                                n   For the diagnosis or treatment of TMJ .
  n   For oral hygiene instructions and:
        n Plaque control
                                                                n   For hospital services .
        n Completion of a claim form                            n   For any unmarried child 19 years of age and
        n Acid etch                                                 over unless he or she is dependent upon you
        n Missed appointments                                       for support, while a full-time student . A full-time
        n Prescription of take home fluoride                        student is one taking at least 12 semester units
        n Diagnostic photographs                                    (or equivalent hours) in a qualified college,
                                                                    university or vocational school . Any exception
  n   For services not completed when insurance ends,
                                                                    for a full-time student will end at age 25 .
      except that certain services which began while insured
      may be covered if completed within 31 days of             n   During any waiting period we require, when you
      termination of coverage .                                     voluntarily end your insurance and re-enroll at
                                                                    a later date . Your waiting period is 2 years and
  n   For procedures that have begun but have not been
                                                                    begins on the date your coverage first ended .
      completed .
                                                                n   Charges for infection control, sterilization and
  n   For services and treatment provided at no charge, with
                                                                    waste disposal .
      or without insurance coverage .
  n   For services in connection with war or any act of
      war, whether declared or undeclared, or condition
      contracted or accident occurring while on full-time
      active duty in the armed forces of any country or
      combination of countries .



                                This is a summary of Exclusions & Limitations Only .
                           For a complete listing, please see the Evidence of Coverage .




                                                                                                                           11
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                          for the way   WE LIVE®




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