MANAGED CARE DENTAL PLANS

CompBenefits does not provide coverage for the following services:

1. Cost of hospitalization and pharmaceuticals.

2. Services which are not Necessary Treatment in the opinion of the Participating Dentist(s) or Specialist(s).

3. Any service which is not consistent with the Normal and/or Usual Services provided by said Participating Dentist(s).

4. Any service performed by a non-participating CompBenefits provider except for emergencies as provided for in the certificate of benefits.

All procedures listed may not be performed by the Participating General Dentist you select. The surcharges shown apply to those American Dental Plan Participating General Dentists who do perform those services and are not applicable for services performed by a specialist. Therefore, you are encouraged to discuss availability of the scheduled services with your Participating General Dentist. Procedures not listed on the schedule of benefits, that are preformed by the selected General Dentist, will be charged at the General Dentist's usual and customary fee less 25%.

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