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EP710 Preferred Schedule
Because we specialize in dental plans, 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.
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 | 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.
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 | 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!
SUMMARY OF BENEFITS

MAXIMUM BENEFITS
Insured Individual and Dependents
|
In-Network
Reimbursements |
Out-of-Network
Reimbursements |
Lifetime |
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Type I, II, III |
Unlimited |
Unlimited |
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Type IV |
$1,000 |
$1,000 |
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Calendar Year |
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Type I, II, III |
$1,000 |
$1,000 |
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Type IV |
$500 |
$500 |
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Deductible*** |
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Type I |
$0 |
$0 |
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Type II, III, IV |
$50 |
$50 |
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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.
*Coverage based on usual, customary and reasonable fees.
**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.
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 CompBenefits 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 semiprecision
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; 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.
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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