 |

 |
ADP Total Source
Dental Members |
 |
 |
 |
|
 |
 |
 |
|
 |
 |
|
 |
 |
 |
|
 |
 |
|
 |
 |
|
 |
 |
|
 |
 |
|
 |
 |
 |
|
 |
 |
|
 |
 |
|
 |
 |
|
 |
 |
|
 |
 |
 |
|
 |
 |
|
 |
 |
|
 |
 |
|
 |
 |
|
 |
 |
 |
|
 |
 |
|
 |
 |
|
 |
|
|
 |
 |
|
 |
 |
|
|
 |


Elite 75 Schedule1Plan Design Summary
 | $50 Deductible (3 per family) |
 | Deductible waived for Type I services |
 | $1000 Annual Maximum |
 | No waiting periods on Type I, II, & III |
1Select a service below |
|
|
|
Services |
|
|
|
|
|
|
|
|
|
 | Type IV Orthodontics (Optional)
(12 month waiting period**)
Dependent children 18 years of age or younger
|
|
50% |
|
|
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 implantor 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. Chewing injuries are not
considered Covered Dental Injuries;
- the replacement of crowns, cast restorations, inlays, onlays or other
laboratory prepared restorations if:
- 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.
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 CompDent
Insurance Company;
- any chewing injury. A chewing injury means an injury which occurs during
the act of chewing or
biting. The injury may be caused by biting on a foreign object not expected
to be a normal
constituent of food; by parafunctional habits, such as chewing on eyeglass
frames or pencils; or by biting down on a suddenly dislodged or loose dental
prosthesis.
- 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;
- 8. 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; however, if the charges are made for the treatment of: (a)
injuries sustained in an accident which happens while the patient is insured
for Dental Benefits
under this policy; or (b) congenital defects of a child born while his or
her parent is insured, they
will not be excluded if they qualify as Covered Dental Expenses. 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; or
- 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.
PREDETERMINATIONIf Covered Dental Expenses for a procedure are expected to be more than $300
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.
CompBenefits Family of Companies
 | CompDent |
 | CompDent Insurance Company |
 | American Dental Plan, Inc. |
 | Oral
Health Services, Inc. |
 | American Prepaid Dental Plan |
 | American Dental Plan of North Carolina, Inc. |
 | National Dental Plans, Inc. |
 | Texas Dental Plans, Inc. |
 | Vision Care, Inc. |
 | Ultimate Optical, Inc. |
|