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Option III - Elite Preferred 510 Schedule
OVERVIEW
Because we specialize in dental, we can bring you benefits and service
that other companies can't match!
Quick Claims Turnaround
CompBenefits' state of the art claims center provides fast reimbursement
of your claims.
Access to Information
Our toll-free customer service number at 1-800-342-5209 has Member
Services Representatives who can provide the answers you need quickly and
thoroughly.
Total Freedom of Choice
The plan provides you with total freedom of choice by allowing you to use
any licensed dentist for treatment. The plan reimburses a percentage of
eligible expenses based on the plan you have chosen.
Any way you add it up, CompBenefits really is the benefits company of
choice!
A complete description of the coverage, including limitations on certain
procedures, is found in the Schedule of Benefits and Certificate of Group
Dental Insurance.
By using one of our PPO providers you have the benefit of reduced
out-of-pocket expenses. You also get additional peace of mind knowing that
our providers go through an extensive credentialing process.
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SUMMARY OF BENEFITS
Partial Listing of
Covered Services |
In-Network
Reimbursements |
Out-of-Network
Reimbursements |
|
 |
 |
 |
 |
Type I Diagnostic &
Preventive |
100% |
80% |
|
Oral Examination (once per six months)
Prophylaxis (cleaning, 2 per year)
Topical Fluoride (children under 16,once per 12 months)
X-Rays (limitations may apply)
Sealants (once per 3 years for children under age 16, for non
carious molars only)
Space Maintainers (for children under age 16)
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|
 |
|
Type II Basic Services |
80% |
60% |
|
Simple Restorative (amalgam, synthetic, or composite fillings)
Emergency Palliative Treatment
Tooth Extraction
X-Rays (limitations may apply)
Endodontics (root canals)
Periodontics (includes treatment of diseases of the gums)
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|
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Type III Major Services |
50% |
50% |
|
Major Restorative (crowns/inlays/onlays)
Bridge, Denture Repair
Prosthetics (bridges and dentures)
|
|
 |
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Type IV Orthodontics |
50% |
50% |
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Dependent children 18 years of age or younger |
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MAXIMUM BENEFITS
Insured Individual and Dependents
|
|
In-Network
Reimbursements |
Out-of-Network
Reimbursements |
|
Lifetime |
 |
Type I, II, III |
Unlimited |
Unlimited |
 |
Type IV |
$1,000 |
$1,000 |
|
 |
|
Calendar Year |
 |
Type I, II, III |
$1,500 |
$1,500 |
 |
Type IV |
$500 |
$500 |
|
 |
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Deductible*** |
 |
Type I |
None |
None |
 |
Type II, III, IV |
$50 |
$50 |
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*Coverage based on contracted fees for the Preferred Provider
Network.
***Maximum of 3 per family.
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MAJOR RESTORATIVE LIMITATIONS
The charges for Major Restorative services will be Covered Dental
Expenses subject to the following:
- the denture or partial denture must replace a Natural Tooth extracted
while insured for Dental Benefits under this policy;
- the fixed bridge (including a resin bonded fixed bridge) must replace
a Natural Tooth extracted while insured for Dental Benefits under this
policy;
- the replacement of a partial denture, full denture, or fixed partial
denture (including a resin bonded bridge), or the addition of teeth to a
partial denture if: (a) replacement occurs at least five years after the
initial date of insertion of the current full or partial denture or resin
bonded bridge; (b) replacement occurs at least five years after the
initial date of insertion of an existing implant or fixed bridge; (c)
replacement prosthesis or the addition of a tooth to a partial denture is
required by the
necessary extraction of a Functioning Natural Tooth while insured for
Dental Benefits under this policy; or (d) replacement
is made necessary by a Covered Dental Injury to a partial denture, full
denture, or fixed partial denture (including a resin
bonded bridge) provided the replacement is completed within 12 months of
the injury;
- the replacement of crowns, cast restorations, inlays, onlays or other
laboratory prepared restorations if: (a) replacement occurs at least five
years after the initial date of insertion; and (b) they are not
serviceable and cannot be restored to function;
- the replacement of an existing partial denture with fixed bridgework,
only if upgrading to fixed bridgework is essential to
the correction of the person's dental condition; and
- the replacement of teeth up to the normal complement of 32.
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EXCLUSIONS
Benefits will not be paid for:
- procedures which are not included in the Schedule of Benefits; which
are not medically necessary; which do not have uniform professional
endorsement; are experimental or investigational in nature; for which the
patient has no legal obligation to pay; or for which a charge would not
have been made in the absence of insurance;
- any procedure, service, or supply which may not reasonably be expected
to successfully correct the patient's dental condition for a period of at
least three years, as determined by CompBenefits Insurance Company;
- crowns, inlays, cast restorations, or other laboratory prepared
restorations on teeth which may be restored with an amalgam or composite
resin filling;
- appliances, inlays, cast restorations or other laboratory prepared
restorations used primarily for the purpose of splinting;
- any procedure, service, supply or appliance, the sole or primary
purpose of which relates to the change or maintenance of vertical
dimension; the alteration or restoration of occlusion including occlusal
adjustment, bite registration, or bite analysis;
- pulp caps, adult fluoride treatments, athletic mouthguards;
myofunctional therapy; infection control; precision or semi-
precision attachments; denture duplication; oral hygiene instruction;
separate charges for acid etch; broken appointments; treatment of jaw
fractures; orthognathic surgery; completion of claim forms; exams required
by third party; personal supplies (e.g. water pik, toothbrush, floss
holder, etc.); or replacement of lost or stolen appliances;
- charges for travel time; transportation costs; or professional advice
given on the phone;
- procedures performed by a Dentist who is a member of Your immediate
family;
- any charges, including ancillary charges, made by a hospital,
ambulatory surgical center, or similar facility;
- charges for treatment rendered: (a) in a clinic, dental or medical
facility sponsored or maintained by the employer of any member of Your
family; or (b) by an employee of the employer of any member of Your
family;
- any procedure, service or supply required directly or indirectly to
diagnose or treat a muscular, neural, or skeletal disorder, dysfunction,
or disease of the temporomandibular joints or their associated structures;
- charges for treatment performed outside of the United States other
than for emergency treatment. Benefits for emergency treatment which is
performed outside of the United States are limited to a maximum of $100
(US dollars) per year;
- the care or treatment of an injury or sickness due to war or an act of
war, declared or undeclared;
- treatment for cosmetic purposes. Facings on crowns or bridge units on
molar teeth will always be considered cosmetic;
- any services or supplies which do not meet the standards set by the
American Dental Association or which are not reasonably necessary, or
customarily used, for dental care;
- procedures that are a covered expense under any other medical plan
(established by the employer) which provides group hospital, surgical, or
medical benefits whether or not on an insured basis;
- a sickness for which the patient can receive benefits under a workers'
compensation act or similar law;
- an injury that arises out of or in the course of a job or employment
for pay or profit;
- charges to the extent that they are more than the Prevailing Fee. If
the amount of the Prevailing Fee for a service cannot be determined due to
the unusual nature of the service, CompBenefits Insurance Company will
determine the amount. CompBenefits Insurance Company will take into
account: (a) the complexity involved; (b) the degree of professional skill
required; and (c) other pertinent factors; or
- orthodontic plan benefits for persons 19 years of age or older.
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PREDETERMINATION
If Covered Dental Expenses for a procedure are expected to be more than
$200 it is recommended that you send a Dental Treatment Plan in prior to
beginning treatment, send preauthorization to:
CompBenefits
P.O. Box 8236
Chicago, IL 60680�8236
You and/or your dentist will be notified of the benefits payable based
upon the Dental Treatment Plan.
This brochure contains a brief description of the plan. A complete
description of the coverage, including limitations on certain procedures is
found in the Schedule of Benefits and Certificate of Group Dental Insurance.
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