enrollment booklet - alpine school districtcurrent market value of gold. • procedures or services...

Plan Year 2014 - 2015

Enrollment Booklet

Table of Contents

Plan Summaries...……………………………………………………….….2-3 DHMO ……………………………………………………………………..….4-8 Elite Choice…………………………………………………………..…….9-10 PPO/MAC ……………………………………………………………….…11-12 TDA-Companion ……………………………………………………....…13-14 How to Find a Dentist…………………………………………………..…...15 Contact Information………………………………………….……….……..15

1

FOR QUESTIONS PLEASE CONTACT:

Alpine Education Association Uniserv Glenda Anderson

(801) 224-2055 ext 102 (801) 224-6137 (fax)

[email protected]

Total Dental Administrators, Inc Customer Service

(888) 422-1995 Option 1 (Toll Free) (801) 268-9740 (Local)

6985 Union Park Center, Suite 675 Salt Lake City, Utah 84047

[email protected]

TDA DHMO TDA Elite Choice

In-Network Only

Approx. 80%

Approx. 55%

100% after $10 copay

15% - 25% Discount

Based Upon Fee Schedule

None

Unlimited

Class III Class IV

None N/A

Class I Preventative

Class II Basic

Class III Major

Class IV Orthodontics

Annual Maximum

Ortho Lifetime

Maximum

Endodontics Periodontics

Deductible

Waiting Periods

Employee

2 Party

Family


None

Class III Class IV

None N/A

Ortho Lifetime

Maximum


Deductible

Waiting Periods


Class II Basic

Class III Major



$1,500.00


Approx 50%

Approx 35%

Approx 75%

No Coverage

80%

50%

15%-25% Discount

100% after $15 copay

In-Network Out-of-Network

Dental Plan

Sept. ‘13 -’14 Rates Sept. ‘14 -’15 Rates Sept. ‘14 -’15 Rates Sept. ‘13 -’14 Rates

Employee

2 Party

Family

$12.32

$25.56

$38.98

$12.32

$25.56

$38.98

$26.93

$52.75

$85.88

$27.47

$54.74

$89.80

2

Annual Maximum

TDA PPO/MAC

Class III

$50 PP/$150 Family

Class III Class IV

12 Months 12 Months

Annual Maximum

Ortho Lifetime

Maximum


Deductible

Waiting Periods

Class II Basic

Class III Major


$1,200.00

$1,000.00 Up to Age 19

70% *

40% *

90% *

50% *

80%

50%

50%

TDA Companion

Class III

$100.00 Lifetime

Class III Class IV

12 Months 12 Months

Annual Maximum

Ortho Lifetime

Maximum


Deductible

Waiting Periods

Class II Basic

Class III Major


$1,000.00

80% **

50% **

100% **

50% **

80%

50%

50%

In-Network Out-of-Network In-Network Out-of-Network


Class I Preventative 100%

$1,000.00 Up to Age 19

100%

Comparison

Employee

2 Party

Family

Employee

2 Party

Family

Sept. ‘13 -’14 Rates Sept. ‘14 -’15 Rates Sept. ‘14 -’15 Rates Sept. ‘13 -’14 Rates

$32.05

$66.35

$107.89

$33.65

$70.65

$115.62

$38.75

$80.24

$130.47

$38.75

$81.73

$133.87

**Highest out-of-network reimbursement available of

any plan offered through Alpine School District.

3

*Out-of-network reimbursement based off of the

contracted in-network TDA discounts.

The TDA DHMO plan is associated with the "DHMO" Network. The TDA DHMO plan is an In-Network only plan that offers the best value for your dollar. This plan

also offers Specialty Care Coverage which allows you to see an Endodontist, Periodontist or Oral Surgeon for the same out of pocket cost as a General Dentist.

DHMO

** ENDODONTIC, PERIODONTIC AND ORAL SURGERY TREATMENTS FROM A PLAN SPECIALIST MUST BE PRE-APPROVED BY THE PLAN ADMINISTRATOR, TDAUT, PRIOR TO ANY SERVICES RENDERED. SPECIALITY CARE SERVICES NOT LISTED ARE DISCOUNTED BY THE RATE FILED WITH TDAUT INC. *** Pedodontic coverage is the discount filed with TDAUT (20-25% off the participating pedodontists regular fee).

DHMO DENTAL COVERAGE DHMO ADVANTAGES

Dental coverage includes dental services and treatment for: • No deductibles

• Diagnostic • No claim forms

• Preventive • No annual or lifetime benefit maximums

• Restorative • Covers pre-existing conditions

• Endodontics • No industry exclusions

• Periodontics • Covers orthodontics (braces)

• Prosthodontics • Local service

• Oral surgery

• TMJ

• Orthodontics

• Cosmetic

Refer to the enclosed Schedule of Benefits and Co-payments for a detailed

listing of covered procedures.

SPECIAL LIMITATIONS

• This Schedule Of Benefits And Co-payments is for non-precious metals only. If gold is used, there will be an additional charge according to the current market value of gold. • Procedures or services not listed will be provided at Usual & Customary fees. *Orthodontic coverage is the discount filed with TDAUT. Please see provider listing for details.

4

ADA Code Procedure Description Diagnostic D0120 Periodic oral exam (twice in any 12 consecutive

month) D0140 Emergency oral exam (during office hours) D0145 Oral exam for patient under 3 years of age D0150 Initial oral exam (once in any 12 consecutive months) D0170 Re-Evaluation - limited, problem focused D0180 Comprehensive periodontal evaluation (once in any 12 consecutive months) D0210 Intraoral - complete including bitewing x-ray (once in a 3 year period) D0220 Single periapical x-ray D0230 Periapical x-ray - each additional x-ray D0270/72Bitewing x-rays - single & two films D0273 Bitewing x-rays - three films (once in a 6 mo period) D0274 Bitewing x-rays - four films (once in a 6 mo period) D0277 Verticle Bitewing x-rays (once in a 6 mo period) D0330 Panoramic film-including bitewing x-rays (once in a 3 year period) D0470 Diagnostic casts D9310 Consultation D9430 Office Visit D9999 Sterilization Preventative D1110 Prophylaxis-Adult (once in a 6 month period) D1120 Prophylaxis-Child (once in a 6 month period) D1203 Fluoride treatment (once in a 12 month period to age

15) D1310 Dietary planning D1330 Preventive dental education, home care D1351 Sealant per tooth D1510 Space maintainer -fixed unilateral D1515 Space Maintainer -fixed bilateral D1520 Space Maintainer -removable unilateral D1525 Space Maintainer -removable bilateral D1550 Recement space maintainer Restorative D2140 Amalgam - 1 surface permanent D2150 Amalgam - 2 surface permanent D2160 Amalgam - 3 surface permanent D2161 Amalgam - 4 or more surfaces permanent D2330 Resin - 1 surface anterior D2331 Resin - 2 surfaces anterior D2332 Resin - 3 surfaces anterior D2335 Resin - 4 or more surfaces anterior D2390 Resin – based composite crown, anterior D2391 Resin - 1 surface posterior D2392 Resin - 2 surface posterior D2393 Resin - 3 surface posterior D2394 Resin - 4 or more surfaces posterior D2510 Inlay metallic - 1 surface D2520 Inlay metallic - 2 surfaces D2530 Inlay metallic - 3 surfaces D2542 Onlay metallic - 2 surfaces D2543 Onlay metallic - 3 surfaces D2544 Onlay metallic - 4 or more surfaces D2710 Acrylic (plastic) crown - lab processed D2720-22 Acrylic w/metal crown D2740 Porcelain crown D2750-52Porcelain w/metal crown D2780-82 3/4 metal crown D2783 3/4 ceramic crown D2790-92 Full crown D2910-20 Recement crown, inlay, facing only D2930 Stainless steel crown primary tooth D2932 Prefabricated resin crown D2933/34 Prefabricated stainless steel crown D2940 Sedative filling D2950 Crown buildup, including any pins D2951 Pin retention per tooth

ADA Code Procedure Description Restorative (Continued) D2952 Cast post and core D2954 Prefabricated post and core D2960 Labial veneer laminate - chairside D2970 Temporary crown (Fractured Tooth) D2980 Repair crown Endodontics** (Treatment from a Plan specialist MUST be pre-approved by the Plan, TDAUT, PRIOR to any services rendered.)

D3110 Pulp capping/direct D3120 Pulp capping/indirect D3220 Therapeutic pulpotomy D3230 Pulpal Therapy (Resorbable Filling) Anterior Primary D3240 Pulpal Therapy (Resorbable Filling) Posterior Primary

D3310 Root Canal Therapy - anterior D3320 Root Canal Therapy - bicuspid D3330 Root Canal Therapy - molar D3346 Retreat Previous RCT anterior D3347 Retreat Previous RCT bicuspid D3348 Retreat Previous RCT molar D3351 Apexification/Recalcification-Initial D3352 Apexification/Recalcification-Interiml D3353 Apexification/Recalcification-Final D3410 Apicoectomy per tooth (anterior only) D3421 Apicoectomy per tooth (bicuspid) D3425 Apicoectomy per tooth (molar) D3426 Apicoectomy per tooth (each add) D3430 Retro fill per tooth D3450 Root amputation D3920 Hemisection Periodontics** (Treatment from a Plan specialist MUST be pre-approved by the Plan, TDAUT, PRIOR to any services rendered.)

D4210 Gingivectomy or gingivoplasty/quad D4211 Gingivectomy or gingivoplasty/tooth D4240 Gingival flap procedure inc. rt. Planning 4+ teeth D4241 Gingival flap procedure inc. rt. Planning 1-3 teeth D4260 Osseous surg/quad (flap entry & closure) 4+ teeth D4261 Osseous surg/tooth (flap entry & closure) 1-3 teeth D4320 Provisional splinting - intracoronal D4321 Provisional splinting - extracoronal D4341 Periodontal scaling & root planing/quad 4+ teeth D4342 Periodontal scaling & root planing/tooth 1-3 teeth D4355 Full mouth debridement D4381 Local Delivery–Chemo to Tissue D4910 Periodontal maintenance following active therapy Removable Prosthodontics D5110 Complete upper denture(3 adj. w/in 60 days) D5120 Complete lower denture(3 adj. w/in 60 days) D5130 Immediate upper denture(4 adj. w/in 60 days) D5140 Immediate lower denture(4 adj. w/in 60 days) D5211/12Upper or lower partial - resin base D5213/14Upper or lower partial - cast metal base w/resin saddles (including conventional clasps, rests & teeth)

D5281 Removable unilateral partial denture D5410-22Denture adjustment(upper, lower, complete or partial) D5510 Repair broken complete denture base D5520 Replace missing/broken teeth denture base D5610 Repair resin saddle or base D5620 Repair cast framework D5630 Repair or replace broken clasp D5640 Replace broken teeth (per tooth) D5650 Add tooth to existing partial denture D5660 Add clasp to existing partial denture D5670/71 Replace all teeth and acrylic-cast metal D5710-21Rebase (upper, lower, complete or partial) D2750-61Reline chairside (Upper, lower, complete or partial) D5850 Reline lab (Upper, lower, complete or D5850 Tissue Reconditioning per denture

N/C

$25 N/C

N/C

$25 N/C

N/C

N/C

N/C N/C

N/C

N/C N/C

N/C

N/C

N/C

$10 N/C

N/C

N/C N/C

N/C N/C

$12

$30+Lab Fee $50+Lab Fee

$30+Lab Fee

$50+Lab Fee $15

Co-Payment

DHMO Option Schedule of Benefits and Copayments

$25 $34

$45

$60 $42

$50

$60 $70

$90

$49 $74

$89

$105 $145

$180

$225 $180

$220

$250 $110

$275+Lab Fee


$250+Lab Fee


$20 $55

$75

$100 $22

$75

$10

$85

N/C

$25 N/C

N/C

$20

$17

$43 $45

$45

$195 $270

$365

20% Discount 20% Discount

20% Discount


20% Discount $250

20% Discount


$85

$95

Co-Payment

$200 $60

$250

$150 $380

$250

$100 $100

$90

$60 $55

20% Discount

$55

$275+Lab Fee


$275+Lab Fee

$275+Lab Fee

$275+Lab Fee

$250 $35

$20+Lab Fee


$25+Lab Fee


$20+Lab Fee

$25+Lab Fee 20% Discount

$25+Lab Fee

$70 $45+Lab Fee

$30

5

ADA Code Procedure Description Fixed Prosthodontics D6010-95 Implant procedures D6100-99 Implant procedures continued D6210-12 Cast pontic D6240-42 Porcelain w/metal pontic D6245 Porcelain ceramic pontic D6250-52 Acrylic pontic D6545 Cast metal retainer for acid etch bridge (Maryland Bridge - per unit) D6720-22 Acrylic w/metal crown retainer D6740 Porcelain ceramic crown retainer D6750-52 Porcelain w/metal crown retainer D6780-83 3/4 metal crown retainer D6790-92 Full metal crown retainer D6920 Connector Bar D6930 Recement bridge - per cemented unit D6940 Stress breaker, simple D6950 Precision attachment D6980 Bridge repair Oral Surgery** (Treatment from a Plan specialist MUST be pre-approved by the Plan, TDAUT, PRIOR to any services rendered.)

D7111 Extraction, coronal remnants – decidusous tooth D7140 Extraction, erupted tooth or exposed roots D7210 Surgical extraction D7220 Soft tissue impaction D7230 Partial bony impaction D7240 Complete bony impaction D7241 Complete bony impaction with complications D7250 Surgical root recovery D7270 Tooth reimplantation & stabilization D7280 Surgical exposure of impacted tooth D7286 Biopsy of oral tissue - soft D7310 Alveoloplasty/quad with extraction 1 to 3 teeth D7311 Alveoloplasty/quad with extraction 4 or more teeth D7320 Aveoloplasty/quad w/out extraction 1 to 3 teeth D7321 Aveoloplasty/quad w/out extraction 4 or more teeth D7471 Removal of exostosis - maxilla or mandible D7510 Intra - oral I & D or abscess D7911 Simple suture (includes post op. visit) D7960 Frenectomy Orthodontics D8010 Limited orthodontic treatment-primary dentition D8020 Limited orthodontic treatment-transitional dentition D8030 Limited orthodontic treatment-adolescent dentition D8040 Limited orthodontic treatment-adult dentition D8050 Interceptive orthodontic treatment-primary dentition D8060 Interceptive orthodontic treatment-transitional dentition D8070 Comprehensive orthodontic treatment transitional dentition D8070 Comprehensive orthodontic treatment adolescent dentition D8090 Comprehensive orthodontic treatment-adult dentition D8210 Removable appliance therapy D8220 Fixed appliance therapy D8660 Pre-orthodontic treatment visit D8670 Periodic orthodontic TX visit D8680 Orthodontic retention-removal of appliance, construct and place retainer(s)

Co-Payment


$275+Lab Fee


$275+Lab Fee

$175

$275+Lab Fee

$275+Lab Fee


$275+Lab Fee

$45 $30

$25+Lab Fee

$150

$25+Lab Fee

Co-Payment

$30 $40

$80

$80 $95

$115

$125 $60

$125

$160 $35+Lab Fee

$80

$40 $200

$85

$265

$65

$0

$140

15-25%Discount

15-25%Discount

15-25%Discount

15-25%Discount

15-25%Discount

15-25%Discount

15-25%Discount

15-25%Discount

15-25%Discount

15-25%Discount

15-25%Discount

15-25%Discount 15-25%Discount

15-25%Discount

ADA Code Procedure Description Orthodontics (Continued) D8690 Orthodontic TX (alter bill to contract) D8691 Repair of orthodontic appliance D8692 Replacement of lost or broker retainer D8693 Rebonding/recementing; and/or repair, as required, of fixed retainers D8999 Unspecified orthodontic procedures Temporomandibular Joint Dysfunction (TMJ) TMJ Treatment Other Services D9110 Emergency palliative treatment D9210 Local anesthetic D9230 Analgesia / Nitrous oxide D9310 Consultation D9430 Office Visit (during regular scheduled hours) D9440 Office visit (after regular scheduled hours) D9940 Nightguard-occlusal guard (limited to one in a 12 month period) D9951 Root Canal Therapy - molar D9952 Occlusal adjustment - complete D9972 Cosmetic Bleaching, Per arch D9973 Cosmetic Bleaching, per tooth D9999 Missed/canceled appointment (without 24 hour notice)

15-25%Discount 15-25%Discount

15-25%Discount

15-25%Discount

15-25%Discount

15-25%Discount

$35

N/C $20

N/C

$10 $35

$155

$25

$90

$110 $10

$25

I. Co-payments - The Co-payment amount in the Schedule Of Benefits and Co-Payments, contained herein are payable by you directly to the Dental Office as treat-ment is received. You should discuss all future payments and costs before new ap-pointments are made. The Dental Office staff will help you plan your dental treatment and payments. II. Specialty Care - Sometimes your selected dentist will identify a problem that is best treated by a specialist. In this case, your dentist will refer you, where available, to a fully qualified specialist in the Total Care Dental Network who specializes in the care you need. Depending on your plan of coverage (refer to your Schedule of Benefits and Co-Payments), treatment provided by a specialist may require Plan authorization. Your selected Plan Provider will initiate this authorization. Eligible dental care services from a specialist are those services specifically listed under the specialist category of the Schedule of Benefits and Co-payments. III. Extended Care - Upon termination of eligibility or termination of the Group Agree-ment, the Plan will complete any procedures started, but only the procedures in pro-gress. IV. Effective Date of Coverage A. Initial enrollment must be made within thirty (30) days following the date of hire or the Employer's period of probation. If enrollment is received prior to the fifteenth (15th) day of the month, coverage will begin on the first day of the following month. If TDAUT does not receive the completed application as required above, the Employee must wait until the next open enrollment period. B. A spouse and child(ren), newly acquired through marriage, must make application within thirty (30) days of marriage. If said application is received prior to the fifteenth (15th) day of the month, coverage will begin on the first day of the following month. Except for newborn natural children and adopted children, who are enrolled within sixty (60) days from the date of the birth of the natural child or sixty (60) days after placement of the adopted child, family members, who do not enroll during the initial enrollment period, cannot enroll until the next annual open enrollment period.

V. Participating Plan Providers (Dentists) A. Benefits Obtained From Plan Providers - Except for out-of area emergency care, benefits are available only from your selected Plan Provider. B. List of Plan Providers - You may obtain a current list of Plan Providers from the Plan's Administrative Office located at 6985 Union Park Center, Suite 675,Salt Lake City, Utah 84047, telephone no. (801) 268-9740 or (800) 880-3536. C. Choosing a Plan Provider -You may choose any Plan Provider from the list of Plan Providers referred to above. Upon request, the Plan Administrator will assist you in selecting a Plan Dentist; but may not recommend any particular dentist. All covered family members must go to the same Plan Provider. You must choose a Plan Provider at the time you enroll. You must have a Plan provider to receive benefits. D. Changing Plan Providers - You may change Plan Providers. If you notify the Plan, in writing, by the fifteenth (15th) day of the month, the change will be effective on the first of the following month. Should your Plan Provider stop participation, the Plan reserves the right to transfer you to another Plan Provider of your choosing

6

DHMO Option Schedule of Benefits and Copayments (Continued)

VI. Emergency Care A. If you are less than fifty (50) miles from your Plan Provider, you should always attempt to obtain emergency care from your Plan Provider FIRST. B. If you are seeking emergency care during normal business hours and your selected Plan Provider is not accessible, you should contact the Plan for assistance at (801) 268-9740 or (800) 880-3536. C. If your Plan Provider is not accessible and after you have made a reasonable attempt to contact the Plan for assistance or you are more than fifty (50) miles from your Plan Provider, then you should seek emergency dental care for the relief of pain, bleeding or swelling from any licensed dentist. Under such circumstances, the Plan will pay up to a maximum of $50.00 per contract year per person. A written itemized statement for these services must be presented to TDAUT, Inc. for reimbursement. If it is neces-sary to have additional treatment, it must be done by your Plan Provider.

VII. Scheduling An Appointment - After your Plan becomes effective, you can schedule an appointment by contacting your selected participating Provider. Your dentist will offer you an appointment generally within thirty (30) days of your call - or within 24 hours for emergency care. Most dental appointments are scheduled Monday through Friday during regular working hours. Each Plan Provider is an independent practitioner who establishes his or her own hours. Some have evening and/or weekend hours. Call your Plan Provider to ask about office hours and the availability of emergency dental services.

VIII. Plan Identification Card - Although an I.D. card will be issued to you, it is not necessary in order to receive dental care form your Plan Provider. Your name will appear on an eligibility list, which is sent to your selected dentist each month.

IX. Workers' Compensation Exclusion - Expenses for which payment is required under applicable Workers' Compensation statutes are not eligible for payment under this dental plan.

X. Coordination of Benefits - This Coordination of Benefits (COB) provision applies to this Plan when a Member and/or Subscriber has other dental care coverages. In the

event benefits apply under two or more dental care coverages, each plan determines its order of benefits using the first of the following rules that apply: A. Non-dependent or Dependent. The plan that covers the person other than as a dependent, such as an employee, member, policyholder retiree or subscriber, is the primary plan and the plan that covers the person as a dependent is the secondary plan. B. Child Covered Under More Than One Plan. Unless there is a court decree stating otherwise, plans covering a child shall determine the order of benefits as follows: 1. For a child whose parents are married or living together if they have never been married: a. The plan of the parent whose birthday falls earlier in the calendar year is the primary plan; or b. If both parents have the same birthday, the plan that has covered the parent longest is the primary plan. 2. For a child whose parents are divorced or separated or are not living together if they have never been married: a. i. If a court decree states that one of the parents is responsible for the child's health care expenses or health care coverage, the responsible parent's plan is primary. ii. If the parent with responsibility has no health care coverage for the child's health care expenses, but the spouse of the responsible parent does have health care coverage for the child's health care expenses, the responsible parent's spouse's plan is the primary plan. b. If a court decree states that both parents are responsible for the child's health care expenses or health care coverage, the provisions ofR590-131-6.B.1. shall determine the order of benefits. c. If a court decree states that the parents have joint custody without stating that one parent has responsibility for the health care expenses or health care cover age of the child the provisions of R590-131-6.B.1. shall determine the order of benefits, or d. If there is no court decree allocating responsibility for the child's health care expenses or health care coverage, the order of benefits for the child are as follows: i. the plan covering the custodial parent; ii. the plan covering the custodial parent's spouse; iii. the plan covering the non-custodial parent; and then iv. the plan covering the non-custodial parent's spouse. e. For a child covered under more than one plan, and one or more of the plans provides coverage for individuals who are not the parents of the child, such as a guardian, the order of benefits shall be determined under R590-131-6.B.1. or 2. as if those individuals were parents of the child. C. Longer or Shorter Length of Coverage. 1. If the preceding rules do not determine the order of benefits, the plan that covered the person for the longer period of time is the primary plan and the plan that covered the person for the shorter period of time is the secondary plan. 2. a. To determine the length of time a person has been covered under a plan, two successive plans shall be treated as one if the claimant was eligible under the second within 24 hours after coverage under the first plan ended. b. The start of a new plan does not include: i. a change in the amount or scope of a plan's benefits; ii. a change in the entity that pays, provides or administers the plan's benefits; or iii. a change from one type of plan to another, such as, from a single employer plan to a multiple employer plan. c. The person's length of time covered under a plan is measured from the person's first date of coverage under that plan. If that date is not readily available, the date the person first became a member of the group shall be used as the date from which to determine the length of time the person's coverage under the pre sent plan has been in force. D. If none of the above rules determine the primary plan, the allowable expenses shall be shared equally between the plans. E. If the plans cannot agree on the order of benefits within 30 calendar days after the plans have received all of the information needed to pay the claim, the plans shall immediately pay the claim in equal shares and deter mine their relative liabilities following payment, except that no plan shall be required to pay more than it would have paid had it been the primary plan.

XI. Third Party Responsibility - In the event a Member and/or Subscriber sustains any illness or injury for which a third party may be responsible, the Plan, up to the amount of benefits paid or provided, shall be entitled to the proceeds of any settlement or judgement which results in a recovery from the third party; but only under the conditions that the covered Member and/or Subscriber is made whole first.

XII. Continuation of Coverage - You and your dependents are entitled to continue coverage, should you and/or your dependents' eligibility under the Plan cease. You must

provide written notification of request for continuation of coverage with appropriate membership dues (premium) within sixty (60) days of the date your eligibility ceases. For continuation under the COBRA Act, if applicable, contact your Employer for details.

XIII. Termination - Benefits under this Plan shall cease upon any of the following events: A. On the date of the expiration of the period for which the last payment was made. B. Upon the date of entry into full-time military service. C. On the last day of the month during which termination notice occurs, or thirty (30) days from the date that the termination notice is received by the Member and/or Sub-scriber, whichever date is later, in the event that a Member and/or Subscriber fails to maintain a satisfactory dentist-patient relationship, i.e. the Plan Provider no longer desires to treat the Member and/or Subscriber. D. In the event premiums are delinquent, services and benefits under the Plan shall be suspended effective on the last day of the month during which the delinquency oc-curred. E. On the date the Plan contract terminates, if not renewed.

XIV. Dental Records - The dental records of the Member and/or Subscriber concerning services performed herein shall remain the property of the Plan dentist.

XV. Customer Service Inquires - Plan Members and/or Subscribers customer service is available by calling TDAUT at (801) 268-9740 or toll-free (800) 880-3536 during

normal business hours. All group dental plan inquires, including grievance procedures are handled byTDA UT.

XVI. Early Termination Penalty - While employed with the Group, the Subscriber agrees to remain enrolled as a Member of the Group Dental Plan for a minimum of one year. Less than one-year membership may result in the Subscriber being billed usual service fees minus premium and Co-payments paid.

7

DHMO Option Schedule of Benefits and Copayments (Continued)

1. Sealants are covered to the age of fifteen (15) and are limited to once per permanent molars only. 2. Periodontal treatment (sub-gingival curettage and root planing) is limited to five quadrants in any thirty-six (36) consecutive months. 3. Replacement of a restoration is covered only when it is dentally necessary. 4. Fixed bridgework shall be covered only when a partial cannot satisfactorily restore the case. If fixed bridges are used when a partial could satisfactorily restore the case, it is considered optional treatment. 5. Replacement of existing bridgework is covered only when it cannot be made satisfactory by repair. 6. Partial dentures are not to be replaced within any five (5) year period from the date of last placement, regardless if last placement occurred while covered under this Plan, unless necessary due to natural tooth loss where the addition or replacement of teeth to the existing partial is not feasible. 7. Full upper and/or lower dentures are not to exceed one each in any five (5) year period from the date of last placement, regardless if last placement occurred while covered under this Plan. Replacement shall be provided by the Plan for an existing full or partial denture only if it is unsatisfactory and cannot be made satisfactory by either reline or repair. 8. Denture relines are limited to two (2) in any year. 9. Services for injuries or conditions, which are covered under Workers' Compensation or Employers' Liability Laws. Services, which, in the opinion of the attending dentist, are not necessary for the patient's dental health. 10. Services of a Pedodontist (children’s dentist) are not covered except as provided herein. 11. Services, which, in the opinion of the attending dentist are not necessary for patient’s dental health are not covered. 12. Temporomandibular joint treatment (TMJ), except as provided herein. 13. Elective or cosmetic dentistry, except as provided herein. 14. Oral surgery requiring the setting of fractures or dislocations. Orthonognathic surgery or extractions solely for orthodontic purposes. 15. Orthognathic surgery or extractions solely for orthodontic purposes are not covered. 16. Treatment of malignancies, cysts or neoplasms or congenital malformations, except congenital anomaly of a tooth or teeth covered from birth, adoption or placement for adoption. 17. Dispensing of drugs is not covered. 18. Hospital charges of any kind are not covered. 19. Loss or theft of dentures or bridgework are not covered. 20. Any procedure of implantation or of an experimental nature, (i.e., a service, procedure, drug or treatment for a specific diagnosis from the appropriate governmental regulatory body) are not covered. 21. General anesthesia or IV/conscious sedation, except as provided herein. 22. Fees incurred for broken or missed appointments (without 24 hours notice) are the Member's responsibility. 23. Dental expenses incurred in connection with any dental procedure started prior to the effective date of coverage are the Member’s responsibility and are not covered. 24. Dental expenses incurred in connection with any dental procedure started after termination of eligibility for coverage are the Member’s responsibility and are not covered. 25. Any procedure performed for the purpose of correcting contour, contact or occlusion, except as provided herein, is not covered. 26. Any procedure to correct tooth structure lost due to attrition, erosion or abrasion. 27. Any procedure that is not specifically listed as a covered benefit is not covered. 28. Provider may refuse treatment to any patient who continually fails to follow a prescribed course of treatment. 29. Any dental treatment, which, in the opinion of the Plan's dental consultant has a poor prognosis is not covered. 30. Night guard (occlusal guard) limited to one each twenty-four (24) months. 31. Services performed by a dentist who is not a Participating Dentist are not covered, except for emergency care as provided herein.

Principle Exclusions and Limitations

Orthodontic Plan Exclusions and Limitations

1. No benefits will apply for a treatment program which began before the Member/Subscriber enrolled in the Orthodontic Plan. 2. No benefits will apply for lost or broken appliances. 3. Extractions are not included as a benefit. 4. Additional fees, for which you are responsible, may be charged by the dentist for: a. Care required in excess of 24 months from the time of banding. b. Gross non-cooperation. c. Accidents occurring during the period of treatment. d. Cases involving surgical orthodontics. e. Cases involving myofunctional therapy of TMJ. 5. If the Member and/or Subscriber relocates to an area and is unable to receive treatment from a member Orthodontist, coverage under the Plan ceases and it becomes the obligation of the Member and/or Subscriber to pay the usual and customary fee of the Orthodontist where the treatment is completed. 6. Choice of an Orthodontist is limited to Orthodontists participating in the Plan or to Orthodontists who will accept the fees outlined in the Plan. 7. If the Member and/or Subscriber becomes ineligible for benefits under this Plan for treatment, coverage under the Plan ceases and it becomes the obligation of the Member and/or Subscriber to pay the remaining balance due the Orthodontist.

8

Elite Choice Welcome to the Elite Choice Group

Dental Plan available exclusively from

Total Dental Administrators.

The Elite Choice Dental Plan

offers you the option of receiving your dental

care from any dentist you choose (Out-Of-Network) or from a

Participating Plan Dentist

(In-Network); and you don’t need to make that

decision until you need dental care! However,

should you elect to receive your dental care

from an In-Network dentist, your out of pocket

costs will be less.

The following is an outline of your dental

coverage. For a complete listing of procedures

please refer to the employee booklet/certificate you will receive

after enrollment. Services not

listed are available on a fee for service basis, no

discount applies.

Annual Maximum Per Person $1,500

D0120 Periodic oral evaluation D0140 Limited oral evaluation D0150 Comprehensive oral eval D0180 Comp perio oral eval D0210 Intraoral-complete (bitewings) included D0220 Intraoral pa first film D0230 Intraoral-pa ea addl film D0272 Bitewings-two films D0274 Bitewings-four films D0277 Vert bitewings-7-8 films D0330 Panoramic film

D1110 Prophylaxis-adult D1120 Prophylaxis-child D1201 Top appl of fluor incld/pxs child D1203 Top appl of fluoride pxs excl-child D1351 Sealant- per tooth D1510 Space maintainer-fixedunilateral D1515 Space maintainerfixed bilateral D1520 Space maintainerremovableunilateral D1525 Space maintainerremovabelbilat D1550 Recementation of space maintainer

$0 $10

$0

$0

$0

$0 $0

$5

$5 $0

$0

$10

$10 $0

$0

$13 $80

$120

$90 $135

$15

D2140 Amalgam-one surface D2150 Amalgam- two surfaces D2160 Amalgam-three surfaces D2161 Amalgam-four or more surfs D2330 Resin-one surface, ant D2331 Resin-two surfaces, ant D2332 Resin-three surfaces, ant D2335 Res-4 or surf-invl inc angle ant. D2390 Resin-based composite crown - anterior D2391 Resin-based composite one surf, post D2392 Resin-based composite two surf, post D2393 Resin-based composite three or more surface, post D2394 Resin-based composite four or more surface, post D2510 Inlay-metallic-one surface D2520 Inlay metallic -two surface D2530 Inlay-metallic three or more surfaces D2710 Crown- resin-laboratory D2720 Crown-resin -high noble metal D2721 Crown-resin-predominantly base metal D2722 Crown-resin -noble metal D2740 Porcelain crown D2750 Crown-porcelain-high noble metal D2751 Crown-porcelain-predom base metalic D2752 Crown-porcelain fused noble metal D2790 Crown-full cast high noble metal D2930 Stainless steel crown D2932 Prefabricated resin crown D2940 Sedative filling D2950 Core build-up, incl any pins D2951 Pin ret/tooth, per tooth D2952 Cast post and core D2954 Prefab post/core D2980 Crown repair

D3110 Pulp cap-direct D3120 Pulp cap-indir D3220 Thera pulpotomy D3310 Root canal-anterior D3320 Root can-bicuspid D3330 Root canal-molar D3410 Apicoectomy/periradicular surg-antr D3430 Retro filling-per root D3450 Root amputatuion-perrt D3920 Hemisection/root removal D3960 Bleaching of tooth

ADA Code Procedure Description

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$19 $22

$33

$33

$58

$11 $9

$13

$21 $30

$48

$30

$18 $32

$13

$8 $51

$54

$73 $88

$13

Preventative


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Restorative $16 $24

$35

$45 $30

$40

$50 $60

$106

$35 $65

$80

$95

$145

$170 $225

$110

$250

$250 $250

$295

$365 $365

$365

$365 $60

$60

$15 $65

$10

$80 $75

$45

$17

$20 $50

$170

$225 $323

$227

$75 $85

$80

$115

$28 $33

$33

$39 $28

$35

$41 $48

$11

$32 $23

$24

$22

$190

$210 $213

$90

$148

$114

$125 $210

$133

$99 $110

$116

$44 $68

$25

$34 $11

$72

$50

$0

$7

$2

$17 $115

$123

$126 $99

$24

$115 $76

$28

Endodontics

9

D4210 Gingivectomy or gingivoplasty-quad 4 or more teeth D4211 Gingivectomy or gingivoplasy-tooth 1 to 3 teeth D4240 Ging flap proc inc root plng/quad 4 or more teeth D4241 Ging flap proc inc root plng/tooth 1 to 3 teeth D4341 Perio scaling and root plng-quad 4 or more teeth D4342 Perio scaling and root plng-tooth 1 to 3 teeth D4355 Full mouth debridement D4910 Perio maint proc following active therapy

D5110 Complete denture max D5120 Complete denture-mand D5130 Immediate denture-max D5140 Immediate denture-mand D5211 Max part denture-resin base D5212 Mand part denture-resin base

D7140 Extraction, erupted tooth or exposed root D7210 Surg rem erup tooth req flap/bone D7220 Remov of impacted tooth-soft tissue D7230 Remov of impacted tooth-par bony D7240 Remov of impacted tooth-comp bony D7510 I&d abscess intraoralsoft tissue

D8000 Orthodontics

D9110 Palliative (er) tx-dent pain-minor D9210 Local anesthetic D9230 Analgesia D9310 Prof consult-diag svc other dentist D9430 Office visit-obser-reg hrs. No servs D9440 Office visit-after regular hours D9940 Occlusal guard, by report D9951 Occlusion adjustment-limited D9952 Occlusion adjustment complete Missed appointment fee


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Periodontics

$175

$50

$210

$135

$80

$53 $50

$50

$375

$375

$395 $395

$310

$310

$30

$65

$75 $100

$125

$65

$51

$10

$56

$30

$26

$16 $21

$14

$204

$204

$236 $236

$178

$178

$27

$26

$39 $52

$53

$36

Removable Prosthodontics

Oral Surgery

Orthodontics

20% Discount

No Coverage

Miscellaneous

$30 $0

$20

$10 $15

$35

$130 $25

$90

$15

$6 $11

$0

$67 $11

$12

$0 $21

$171

1. In the first twelve months that a person is insured if the person is a Late Entrant; except

for exams, cleanings and fluoride application. The benefits are limited to procedures

numbered 0120, 0130, 0140, 0150, 1110, 120, 1201and 1203.

2. For any treatment which is for cosmetic purposes, or to correct congenital malformations,

other than medically necessary treatment of congenital cleft in the lip or pallate, or both.

3. To replace any prosthetic appliance, crown, inlay or onlay restoration, or fixed bridge

within five years of the date of the last placement of these items. But if a replacement

is required because of an accidental bodily injury sustained while the Insured is

covered under this section, it will be a Covered Expense.

4. For initial placement of any prosthetic appliance or fixed bridge unless such placement

is needed because of the extraction of one or more natural teeth while the Insured is

covered under this section. But the extraction of a third molar (wisdom tooth) will not

qualify under the above. Any such appliance or fixed bridge must include the replacement

of the extracted tooth or teeth.

5. For any procedure begun before the Insured was covered under this section.

6. For any procedure begun after the Insured’s insurance under this section terminates; or

for any prosthetic dental appliances installed or delivered more than 90 days after the In-

sured’s insurance under this section terminates.

7. To replace lost or stolen appliances.

8. For appliances, restorations, or procedures to:

a. alter vertical dimension;

b. restore or maintain occlusion;

c. splint or replace tooth structure lost as a result of abrasion or attrition; or

d. treat disturbances of the temporomandibular joint.

9. For any procedure which is not shown on

10. For education or training in, and supplies used for, dietary or nutritional counseling,

personal oral hygiene or dental plaque control.

11. For the completion of claim forms.

12. For sealants which are:

a. not applied to a permanent molar.

b. applied after attaining age 17.

c. applied to a molar more than once.

13. Subgingival curettage or root planing (procedure numbers 4220, 4340 and 4341) unless

the presence of periodontal disease is confirmed by both x-rays and pocket depth summaries

of each tooth involved.

14. Because of an injury arising out of, or in the course of, work for wage or profit.

15. By an Insured because of a sickness, injury or condition for which he or she is eligible

for benefits under Worker’s Compensation or similar laws.

16. For charges for which the Insured is not liable or which would not have been made had

no insurance been in force.

17. For services which are not recommended by a dentist or which are not required for

necessary care and treatment.

18. Because of war or any act of war, declared or not.

19. To an Insured if payment is not legal where the Insured is living when expenses are

incurred.

20. Any services related to: equilibration; bite registration or bite analysis.

21. Crowns for the purpose of periodontal splinting.

22. Charges for: any implants; precision or semiprecision attachments, and any endodontic

treatment associated with it; other customized attachments.

23. For endodontic treatment of the same tooth within a three (3) year period.

24. For root canal retreatment when it has not been demonstrated that unusual morphologi-

cal or pathological conditions exist and when performed by a non-endodontic specialist.

25. For more than one filling for each tooth surface in a 24 month period.

26. For non-surgical periodontal treatment more than once in two (2) year period.

27. For surgical periodontal treatment more than once in a three (3) year period.

28. For crown build-ups when less than three (3) of the five (5) Tooth surfaces are de-

stroyed.

29. For crown build-ups (pin, bonded, or post and core) more than once in a five (5) year

period.

Covered Expenses Will Not Include and No Benefits Will Be Payable:

Exclusions and Limitations

10

PPO/MAC Plan

Welcome to the PPO/MAC Dental Plan underwritten by Companion Life Insurance Company.

The PPO/MAC Dental Plan offers you the option of receiving your dental care from any

dentist you choose (Out-of-Network) or from a Participating Plan Dentist (In-Network); and you don’t need to make that decision until you need dental care! However, should you elect to

receive your dental care from an In-Network dentist your out of pocket costs will be less.

The following is a brief outline of your dental coverage. For additional information please refer to the employee booklet/certificate you will

receive after enrollment or contact TDA.

(In-Network) (Out-of-Network) Class I – Preventive 100% 90%* -Oral Examinations (two every twelve months) -Cleanings (once every six months) -X-Rays (bite-wings once every six months) -Pallitave Emergency Treatment Class II – Basic Dentistry 80% 70%* -Restorations (fillings) -Extractions Class III – Major Dentistry 50% 40%* -Crowns -Dentures -Endodontics (root canal therapy) -Periodontal Services (treatment of gum tissue) -Bridges -Other Prosthetic Services -Oral Surgery Class IV – Orthodontics 50% 50%*

Deductible: $50.00 Annual Deductible Per Person (Max 3 per family, waived for Class I & IV)

Maximum Benefit: $1,200.00 per person per calendar year for all Class I, II & III expenses

Lifetime Orthodontic Maximum: $1,000.00 per child under the age of 19 only

Total Dental Administrators, Inc. 6985 Union Park Center, Suite 675

Salt Lake City, Utah 84047 Toll Free: (800) 880-3536 – Local: (801) 268-9740

Fax: (801) 268-9873 Web: www.TDAdental.com

E-mail: [email protected]

Class III Waiting Period: 12 Months Class IV Waiting Period: 12 Months Applies to new enrollees only *Subject to TDA’s Allowable MAC Fee’s (Maximum Allowable Charge)

11

16) Because of an Insured’s injury arising out of, or in the

course of, work for wage or profit.

17) For an Insured’s sickness, injury or condition for which he

or she is eligible for benefits under any Worker’s Com-

pensation act or similar laws.

18) For charges for which the Insured is not liable or which

would not have been made had no insurance been in force.

19) For services which are not recommended by a dentist, not

required for necessary care and treatment, or do not have a

reasonable prognosis.

20) Because of war or any act of war, declared or not, or while

on full-time active duty in the armed forces of any coun-

try.

21) To an Insured if payment is not legal where the Insured is

living when expenses are incurred.

22) For any services related to: equilibration, bite registration

or bite analysis.

23) For crowns for the purpose of periodontal splinting.

24) For charges for: any implants; overdentures; precision or

semi-precision attachments and associated endodontic

treatment; other customized attachments; or specialized

prosthodontic techniques or characterizations.

25) For charges for myofunctional therapy, orthognathic sur-

gery or athletic mouthguards.

26) For procedures for which benefits are payable under the

employer’s medical expense benefits plan for employees

and their dependents.

27) For any procedure which is not shown on the List of

Dental Procedures.

28) For more than one filing for each tooth surface in a 24

month period.

29) For non-surgical periodontal treatment more than once in

a two (2) year period.

30) For surgical periodontal treatment more than once in a

three (3) year period.

31) For crown build-ups when less than three (3) of the five

(5) tooth surfaces are destroyed

32) For crown build-ups (pin, bonded, or post and core) more

than once in a five (5) year period.

33) For root canal retreatment when it has not been

demonstrated that unusual morphological or pathological

Conditions exist and when performed by a non-

Predetermination of Benefits: As a service to protect the insured, Companion Life will provide predetermination of benefits for recom-mended treatment plans that exceed $300. This predetermination of benefits explains which of the recommended procedures will be covered and at what amount. This benefit helps insured better understand their coverage. The insured should submit the treatment plan to Companion Life for review and predetermination of benefits before the service be-

Benefits Continued


1) For major services in the first 12 months that the Insured is

covered, except as may be provided in the Takeover Benefits

provision.

2) For any treatment which is for cosmetic purposes or to

correct congenital malformations, except for medically

necessary care and treatment of congenital cleft lip and

palate.

3) To replace any prosthetic appliance, crown, inlay or onlay

restoration, or fixed bridge within five years of the date of the

last placement of these items, unless required because of an

4) accidental bodily injury sustained while the Insured is covered.

Replacement is not covered if the item can be repaired.

5) For initial placement of any prosthetic appliance or fixed

bridge unless such placement is needed because of the

extraction of natural teeth during the same period of con-

tinuous coverage. But the extraction of a third molar,

(wisdom tooth) will not qualify the item for payment.

Any such appliance or fixed bridge must include the re

placement of the extracted tooth or teeth. Coverage does

not include the part of the cost that applies specifically to replace-

ment of teeth extracted prior to the period of coverage.

6) For addition of teeth to an existing prosthetic appliance or fixed

bridge unless for replacement of natural teeth extracted during the

same period of continuous coverage.

7) For any expense incurred or procedure begun before the Insurer’s

current period of continuous coverage.

8) For any expense incurred or procedure begun after the Insured’s

insurance under this section terminates, except for a prosthetic

appliance, fixed bridge, crown, or inlay or onlay restoration for

which both (a) the procedure begins before the insurance ends

and (b) the item’s final placement is within 90 days after

9) insurance ends.

10) To duplicate appliances or replace lost or stolen appliances.

11) For appliances restorations or procedures to:

a) Alter vertical dimensions;

b) Restore or maintain occlusion

c) Splint or replace tooth structure lost as a result of abrasion or

attrition; or

d) Treat jaw fractures or disturbances of the temporomadibular joint.

12) For educational training in, and supplies used for, dietary or

nutritional counseling, personal oral hygiene or dental plaque

control.

13) For broken appointments or the completion of claim forms.

14) For sealants which are:

a) Not applied to a permanent molar;

b) Applied before age 6 or after attaining age 16;or

c) Reapplied to a molar within three years from the date of a previous

sealant application. Frustrating

15) For subgingival curettage or root planing (procedure numbers

4220 and 4341) unless the presence of periodontal disease is con

firmed by both x-rays and pocket depth summaries of each tooth

involved.

Limitations

PPO/MAC 12

TDA Companion

Welcome to the TDA-Companion Group Indemnity Dental Plan underwritten by Companion Life Insurance Company.

The TDA-Companion Dental Plan offers you the option of receiving your

dental care from any dentist you choose (Out-of-Network) or from a Participating Plan Dentist (In-Network); and you don’t need to make that

decision until you need dental care! However, should you elect to receive your dental care from an In-Network dentist your out of pocket costs will be less.

The following is a brief outline of your dental coverage. For additional information please refer to the employee booklet/certificate you will receive after enrollment or contact TDA.

(In-Network) (Out-of-Network) Class I – Preventive 100% 100%* -Oral Examinations (two every twelve months) -Cleanings (once every six months) -X-Rays (bite-wings once every six months) -Pallitave Emergency Treatment Class II – Basic Dentistry 80% 80%* -Restorations (fillings) -Extractions Class III – Major Dentistry 50% 50%* -Crowns -Dentures -Endodontics (root canal therapy) -Periodontal Services (treatment of gum tissue) -Bridges -Other Prosthetic Services -Oral Surgery Class IV – Orthodontics 50% 50%*

Deductible: $100.00 Lifetime Deductible Per Person

Maximum Benefit: $1,000.00 per person per calendar year for all Class I, II & III expenses

Lifetime Orthodontic Maximum: $1,000.00 per child under the age of 19 only

Total Dental Administrators, Inc. 6985 Union Park Center, Suite 675

Salt Lake City, Utah 84047 Toll Free: (800) 880-3536 – Local: (801) 268-9740

Fax: (801) 268-9873 Web: www.TDAdental.com

E-mail: [email protected]

Class III Waiting Period: 12 Months Class IV Waiting Period: 12 Months Applies to new enrollees only *Subject to TDA’s Allowable MPR Fee’s (Maximum Plan Reimbursement)

13

13) For subgingival curettage or root planing (procedure num-

bers 4220 and 4341) unless the presence of periodontal

disease is confirmed by both x-rays and pocket depth sum-

maries of each tooth involved.

14) Because of an Insured’s injury arising out of, or in the

course of, work for wage or profit.

15) For an Insured’s sickness, injury or condition for which he

or she is eligible for benefits under any Worker’s Com-

pensation act or similar laws.

16) For charges for which the Insured is not liable or which

would not have been made had no insurance been in force.

17) For services which are not recommended by a dentist, not

required for necessary care and treatment, or do not have a

reasonable prognosis.

18) Because of war or any act of war, declared or not, or while

on full-time active duty in the armed forces of any coun-

try.

19) To an Insured if payment is not legal where the Insured is

living when expenses are incurred.

20) For any services related to: equilibration, bite registration

or bite analysis.

21) For crowns for the purpose of periodontal splinting.

22) For charges for: any implants; overdentures; precision or

semi-precision attachments and associated endodontic

treatment; other customized attachments; or specialized

prosthodontic techniques or characterizations.

23) For charges for myofunctional therapy, orthognathic sur-

gery or athletic mouthguards.

24) For procedures for which benefits are payable under the

employer’s medical expense benefits plan for employees

and their dependents.

Predetermination of Benefits: As a service to protect the insured, Companion Life will provide predetermination of benefits for recom-mended treatment plans that exceed $300. This predetermination of benefits explains which of the recommended procedures will be covered and at what amount. This benefit helps insured better understand their coverage. The insured should submit the treatment plan to Companion Life for review and predetermination of benefits before the service be-

TDA-Companion Benefits Continued


1) For major services in the first 12 months that the Insured is

covered, except as may be provided in the Takeover Benefits

provision.

2) For any treatment which is for cosmetic purposes or to

correct congenital malformations, except for medically

necessary care and treatment of congenital cleft lip and

palate.

3) To replace any prosthetic appliance, crown, inlay or onlay

restoration, or fixed bridge within five years of the date of the

last placement of these items, unless required because of an acci-

dental bodily injury sustained while the Insured is covered. Re

placement is not covered if the item can be repaired.

4) For initial placement of any prosthetic appliance or fixed

bridge unless such placement is needed because of the

extraction of natural teeth during the same period of con

tinuous coverage. But the extraction of a third molar,

(wisdom tooth) will not qualify the item for payment.

Any such appliance or fixed bridge must include the re

placement of the extracted tooth or teeth. Coverage does

not include the part of the cost that applies specifically to replace-

ment of teeth extracted prior to the period of coverage.

5) For addition of teeth to an existing prosthetic appliance or fixed

bridge unless for replacement of natural teeth extracted during the

same period of continuous coverage.

6) For any expense incurred or procedure begun before the Insurer’s

current period of continuous coverage.

7) For any expense incurred or procedure begun after the Insured’s

insurance under this section terminates, except for a prosthetic

appliance, fixed bridge, crown, or inlay or onlay restoration for

which both (a) the procedure begins before the insurance ends

and (b) the item’s final placement is within 90 days after insur-

ance ends.

8) To duplicate appliances or replace lost or stolen appliances.

9) For appliances restorations or procedures to:

a) Alter vertical dimensions;

b) Restore or maintain occlusion

c) Splint or replace tooth structure lost as a result of abrasion or

attrition; or

d) Treat jaw fractures or disturbances of the temporomadibular joint.

10) For educational training in, and supplies used for, dietary or nu-

tritional counseling, personal oral hygiene or dental plaque

control.

11) For broken appointments or the completion of claim forms.

12) For sealants which are:

a) Not applied to a permanent molar;

b) Applied before age 6 or after attaining age 16;or

c) Reapplied to a molar within three years from the date of a previous

sealant application. Frustrating

Limitations

14

How to Find a TDA Dentist

Log on to www.TDAdental.com

Click on “Find a Provider”

Select Your Dental Plan Network–

PPO (TDA-Companion, PPO/MAC and Elite Choice plans) TDA DHMO

Search for Dentists by zip code or City/State or

Click Optional Search Items and search by Last Name, Office Name, Office Address and/or Phone Number

Make sure your Dentist accepts the plan in which you are enrolling

15

FOR QUESTIONS PLEASE CONTACT:

Alpine Education Association Uniserv Glenda Anderson

(801) 224-2055 ext 102 (801) 224-6137 (fax)

[email protected]

Total Dental Administrators, Inc Customer Service

(888) 422-1995 Option 1 (Toll Free) (801) 268-9740 (Local)

6985 Union Park Center, Suite 675 Salt Lake City, Utah 84047

[email protected]

Total Dental Administrators, Inc.

6985 Union Park Center, Suite 675

Salt Lake City, Utah 84047

Local (801) 268-9740

Toll Free (800) 880-3536

Total Dental Administrators, Inc.

2111 East Highland Avenue, Suite 250

Pheonix, Arizona 85016

Local (602) 266-1995

Toll Free (888) 422-1995www.TDAdental.com

� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � ��

Questions?Call 1-888-422-1955 to speak with a friendly,

knowledgeable Member Service Specialist, or visit TDAdental.com.

2014 -EOBPROVD

enrollment booklet - alpine school districtcurrent market value of gold. • procedures or services...

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