Option I - PPO/Indemnity Plan
(EP510 with Ortho) Schedule

OVERVIEW
SUMMARY OF BENEFITS
MAXIMUM BENEFITS
MAJOR RESTORATIVE LIMITATIONS
EXCLUSIONS
PREDETERMINATION

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!

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SUMMARY OF BENEFITS

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MAXIMUM BENEFITS

Insured Individual and Dependents

A complete description of the coverage, including limitations on certain procedures, is found in the Schedule of Benefits and Certificate of Group Dental Insurance.

*Coverage based on contracted fees for the Preferred Provider Network.

**Time served on the employer's immediately preceding group dental plan may be credited towards this plan's waiting periods, subject to Underwriting approval.

***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:

1. the denture or partial denture must replace a Natural Tooth extracted while insured for Dental Benefits under this policy;
    
2. the fixed bridge (including a resin bonded fixed bridge) must replace a Natural Tooth extracted while insured for Dental Benefits under this policy;
    
3. 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. Chewing injuries are not considered Covered Dental Injuries;
    
4. the replacement of crowns, cast restorations, inlays, onlays or other laboratory prepared restorations if:
    
5. replacement occurs at least five years after the initial date of insertion; and (b) they are not serviceable and cannot be restored to function;
    
6. 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:

1. 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;
    
2. 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;
    
3. 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.
    
4. crowns, inlays, cast restorations, or other laboratory prepared restorations on teeth which may be restored with an amalgam or composite resin filling;
    
5. appliances, inlays, cast restorations or other laboratory prepared restorations used primarily for the purpose of splinting;
    
6. 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;
    
7. pulp caps, adult fluoride treatments, athletic mouth guards; 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;
    
9. procedures performed by a Dentist who is a member of Your immediate family;
    
10. any charges, including ancillary charges, made by a hospital, ambulatory surgical center, or similar facility;
     
11. 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;
     
12. 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;
     
13. 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;
     
14. the care or treatment of an injury or sickness due to war or an act of war, declared or undeclared;
     
15. 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;
     
16. 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;
     
17. 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;
     
18. a sickness for which the patient can receive benefits under a workers' compensation act or similar law;
     
19. an injury that arises out of or in the course of a job or employment for pay or profit; or
     
20. 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.
     

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PREDETERMINATION

If 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 information 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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