advantage What to expect from your dental plan: The Advantage of Good Oral Health Get more out of your dental

advantage What to expect from your dental plan: Life brings all manner of surprises – some of them good, some of them not. No matter how much you plan...
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advantage What to expect from your dental plan: Life brings all manner of surprises – some of them good, some of them not. No matter how much you plan for now and the future, it is very likely that something will come along that leaves you wondering how you are going to pay for it – like dental problems. Your teeth may be perfectly healthy right now, but CompBenefits’ Advantage plan will give you the security you need in case you are looking at expensive dental treatment down the road. The CompBenefits Advantage plan is a new generation dental plan (which takes the best from DHMOs as well as traditional indemnity insurance). And Advantage is the dental benefit of choice for thousands of CompBenefits members who depend on a company that has been helping people maintain good oral health for more than 25 years. The CompBenefits Advantage plan is easy to use: you'll be free from deductibles, claim forms, waiting periods, and benefits maximums - freedom you wont find with other insurance plans. Plus, you'll get a network that is larger than our traditional managed care plans. You'll make a small copayment, and routine cleanings and x-rays are covered at 100 percent every six months. Additionally, topical fluoride for children up to age 16, and local anesthesia are covered 100 percent.

Get more out of your dental plan @ www.mycompbenefits.com Need to find a dentist closer to you? You can do all of this and more at www.mycompbenefits.com. Registering for this service is simple and will give you access to your plan benefits, including your benefit information, claims status, a list of providers and the option to change your account information. Just a few clicks of the mouse, and you’ll be checking out your benefits in no time.

SSAVN

The Advantage of Good Oral Health

ADVANTAGE - AVN1 Office Visit Co-pay General Provider $5 / Specialist Provider $15

schedule of benefits and subscriber copayments ADA CODE

PROCEDURE

PATIENT PAYS

ADA CODE

PROCEDURE

D0120

Periodic oral examination (limit 2 every 12 months) ...........................$0.00 Limited oral evaluation - problem focused .....$0.00 Comp oral evaluation - new / established patient ...................................$0.00 DTL&EXT oral evaluation - problem focused report .........................................$0.00 Re-evaluation - limited problem focused .........$0.00 Comp periodontal evaluation new / est patient .....................................$0.00 Intraoral, complete with bitewings (limit one every 3 years) ............................$0.00 Intraoral, periapical - first film .....................$0.00 Intraoral, periapical each additional film ......$0.00 Intraoral, occlusal film ...............................$0.00 Extraoral, first film .....................................$0.00 Extraoral, each additional film ....................$0.00 Bitewing, single film (limit two every 12 months) .....................................$0.00 Bitewing, two films (limit two every 12 months) .....................................$0.00 Bitewing, four films (limit two every 12 months) .....................................$0.00 Vertical Bitewings (limit two every 12 months) .....................................$0.00 Panoramic film (limit one every 3 years) .......$0.00 Diagnostic Casts ......................................$0.00 Prophylaxis, adult (limit 1 every 6 months) ...............................................$0.00 Prophylaxis, child (limit 1 every 6 months) ...............................................$0.00 Fluoride, inc. prophy - child (limit 2 every 12 months for child < 16) .......$0.00 Fluoride, exc. prophy - child (limit 2 every 12 months for child < 16) .......$0.00 Sealant, per tooth (limit 1 per tooth every 12 months for child < 13) .................$0.00 Space maintainer, fixed unilateral ..............$53.00 Space maintainer, fixed bilateral ...............$70.00 Space maintainer, removable unilateral ......$66.00 Space maintainer, removable bilateral .......$91.00 Recement space maintainer ......................$12.00 Amalgam, one surface, primary or permanent .........................................$24.00 Amalgam, two surfaces, primary or permanent .........................................$31.00 Amalgam, three surfaces, primary or permanent .........................................$37.00 Amalgam, four or more surfaces, primary or permanent .............................$46.00

D2330

Resin-based composite one surface, anterior ...............................$24.00 Resin-based composite two surfaces, anterior ..............................$31.00 Resin-based composite three surfaces, anterior ............................$38.00 Resin-based composite - four or more surfaces or incisal angle, anterior ..............$45.00 Resin-based composite crown anterior ........$49.00 Resin-based composite one surface, posterior .............................$28.00 Resin-based composite two surfaces, posterior ............................$37.00 Resin-based composite three surfaces, posterior ...........................$46.00 Resin-based composite - four or more surfaces, posterior ..................................$56.00 Inlay - metallic one surface (limit 1 per tooth every 5 years) ..............$313.00 Inlay - metallic two surfaces (limit 1 per tooth every 5 years) ..............$355.00 Inlay - metallic - 3 or more surfaces (limit 1 per tooth every 5 years) ..............$410.00 Onlay - metallic two surfaces (limit 1 per tooth every 5 years) ..............$402.00 Onlay - metallic three surfaces (limit 1 per tooth every 5 years) ..............$420.00 Onlay - metallic four or more surfaces (limit 1 per tooth every 5 years) ..............$437.00 Inlay, porcelain/ceramic - one surface (limit 1 per tooth every 5 years) ..............$368.00 Inlay, porcelain/ceramic - two surfaces (limit 1 per tooth every 5 years) ..............$389.00 Inlay, porcelain/ceramic - three or more surfaces (limit 1 per tooth every 5 years) .....................................$414.00 Onlay, porcelain/ceramic - two surfaces (limit 1 per tooth every 5 years) ..............$403.00 Onlay, porcelain/ceramic - three surfaces (limit 1 per tooth every 5 years) ..............$434.00 Onlay, porcelain/ceramic - four or more surfaces (limit 1 per tooth every 5 years) .....................................$461.00 Inlay - resin-based composite one surface (limit 1 per tooth every 5 years) .....................................$242.00 Inlay - resin-based composite two surfaces (limit 1 per tooth every 5 years) .....................................$288.00 Inlay - resin-based composite three or more surfaces (limit 1 per tooth every 5 years) ........................$303.00

D0140 D0150 D0160 D0170 D0180 D0210 D0220 D0230 D0240 D0250 D0260 D0270 D0272 D0274 D0277 D0330 D0470 D1110 D1120 D1201 D1203 D1351 D1510 D1515 D1520 D1525 D1550 D2140 D2150 D2160 D2161

ADVNAT4321 (04/06)

D2331 D2332 D2335 D2390 D2391 D2392 D2393 D2394 D2510 D2520 D2530 D2542 D2543 D2544 D2610 D2620 D2630 D2642 D2643 D2644 D2650 D2651 D2652

Current Dental Terminology © 2004 American Dental Association. All rights reserved.

PATIENT PAYS

ADVANTAGE - AVN1 Office Visit Co-pay General Provider $5 / Specialist Provider $15

schedule of benefits and subscriber copayments ADA CODE

PROCEDURE

PATIENT PAYS

ADA CODE

PROCEDURE

D2662

Onlay - resin-based composite two surfaces (limit 1 per tooth every 5 years) .....................................$263.00 Onlay - resin-based composite three surfaces (limit 1 per tooth every 5 years) .....................................$310.00 Onlay - resin-based composite four or more surfaces (limit 1 per tooth every 5 years) .....................................$332.00 Crown resin based composite indirect (limit 1 per tooth every 5 years) ..............$187.00 Crown - resin with high noble metal (limit 1 per tooth every 5 years) ..............$461.00 Crown - resin with predominantly base metal (limit 1 per tooth every 5 years) ......$432.00 Crown - resin with noble metal (limit 1 per tooth every 5 years) ..............$441.00 Crown, porcelain/ceramic substrate (limit 1 per tooth every 5 years) ..............$473.00 Crown, porcelain fused to high noble metal (limit 1 per tooth every 5 years) ......$466.00 Crown, porcelain fused to predom base metal (limit 1 per tooth every 5 years) ......$434.00 Crown, porcelain fused to noble metal (limit 1 per tooth every 5 years) ......$445.00 Crown, full cast high noble metal (limit 1 per tooth every 5 years) ..............$450.00 Crown, full cast predom base metal (limit 1 per tooth every 5 years) ..............$426.00 Crown, full cast noble metal (limit 1 per tooth every 5 years) ..............$434.00 Recement inlay only / part coverage restoration .............................................$41.00 Recement crown ....................................$42.00 Prefabricated stainless steel crown primary tooth .......................................$115.00 Prefabricated stainless steel crown permanent tooth ...................................$131.00 Prefabricated resin crown ......................$142.00 Sedative Filling ......................................$44.00 Core buildup including pins ...................$110.00 Pin retention - per tooth, in addition to restoration .........................................$23.00 Cast post & core in addition to crown .....$168.00 Prefabricated post & core in addition to crown .............................................$139.00 Tx pulp-remv pulp coronal dentinocementl junc ................................$75.00 Root canal - Anterior .............................$315.00 Root canal - Bicuspid ............................$385.00 Root canal - Molar ...............................$497.00

D3346

Retreatment of previous RCT therapy, anterior ..............................................$424.00 Retreatment of previous RCT therapy, bicuspid .............................................$500.00 Retreatment of previous RCT therapy, molar .................................................$601.00 Apicoectomy/periradicular surgery, anterior ..............................................$361.00 Apicoectomy periradicular surgery bicuspid .............................................$394.00 Apicoectomy periradicular surgery molar .................................................$445.00 Apicoectomy/periradicular surgery .........$148.00 Retrograde filling - per root ....................$109.00 Gingivect/plsty 4/> cntig/bound teeth spaces - quad (limit 1 every 12 mos.) ......$358.00 Gingivect/plsty 1-3 cntig/bound teeth spaces - quad (limit 1 every 12 mos.) ......$153.00 Gingivect/flp proc 4/> cntig/bound teeth spaces - quad (limit 1 every 12 mos.) ......$421.00 Gingivect/flp proc 1-3 cntig/bound teeth spaces - quad (limit 1 every 12 mos.) ......$217.00 Clinical crown lengthening hard tissue ..........................................$481.00 Osseous surg 4/> contig/bound teeth spaces - quad .....................................$680.00 Osseous surg 1-3 contig/bound teeth spaces - quad .....................................$354.00 Prdontal scaling & root planing 4/more teeth - quad (limit 2 per quad every 12 months) ...................................$39.00 Prdontal scaling & root planing 1-3 teeth - quad (limit 2 per quad every 12 months) ...................................$21.00 Full Mouth Debridement to enable comprehensive evaluation and diagnosis.....$26.00 Periodontal Maintenance (limit 2 every 12 months) ...........................................$23.00 Complete denture – maxillary (limit 1 every 5 years) ...........................$642.00 Complete denture – mandibular (limit 1 every 5 years) ...........................$642.00 Immediate denture – maxillary (limit 1 every 5 years) ...........................$700.00 Immediate denture – mandibular (limit 1 every 5 years) ...........................$700.00 Maxillary partial denture, resin base (limit 1 every 5 years) ...........................$542.00 Mandibular partial denture, resin base (limit 1 every 5 years) ...........................$629.00 Max part dentr - cast metl frmewrk w/ resin base (limit 1 every 5 years) .......$709.00

D2663 D2664 D2710 D2720 D2721 D2722 D2740 D2750 D2751 D2752 D2790 D2791 D2792 D2910 D2920 D2930 D2931 D2932 D2940 D2950 D2951 D2952 D2954 D3220 D3310 D3320 D3330

ADVNAT4321 (04/06)

D3347 D3348 D3410 D3421 D3425 D3426 D3430 D4210 D4211 D4240 D4241 D4249 D4260 D4261 D4341 D4342 D4355 D4910 D5110 D5120 D5130 D5140 D5211 D5212 D5213

Current Dental Terminology © 2004 American Dental Association. All rights reserved.

PATIENT PAYS

ADVANTAGE - AVN1 Office Visit Co-pay General Provider $5 / Specialist Provider $15

schedule of benefits and subscriber copayments ADA CODE

PROCEDURE

PATIENT PAYS

ADA CODE

PROCEDURE

D5214

Mnd part dentr - cast metl frmewrk w/ resin base (limit 1 every 5 years) .......$709.00 Adjust complete denture – Maxillary ..........$35.00 Adjust complete denture – Mandibular .......$35.00 Adjust partial denture – Maxillary ..............$35.00 Adjust partial denture – Mandibular ..........$35.00 Repair broken complete denture base ........$70.00 Replace missing or broken teeth complete denture ...................................$59.00 Repair resin denture base ........................$76.00 Repair cast framework ............................$82.00 Repair or replace broken clasp ...............$100.00 Replace broken teeth - per tooth ...............$64.00 Add tooth to existing partial denture ..........$88.00 Add clasp to existing partial denture ........$105.00 Rebase complete maxillary denture ..........$261.00 Rebase complete mandibular denture ......$249.00 Rebase maxillary partial denture .............$246.00 Rebase mandibular partial denture ..........$246.00 Reline complete maxillary denture ...........$147.00 Reline complete mandibular denture ........$147.00 Reline maxillary partial denture ...............$135.00 Reline mandibular partial denture ............$135.00 Reline complete maxillary denture ...........$196.00 Reline complete mandibular denture ........$196.00 Reline maxillary partial denture ...............$193.00 Reline mandibular partial denture ............$193.00 Tissue conditioning, maxillary ...................$61.00 Tissue conditioning, mandibular ................$61.00 Pontic, cast high noble metal (limit 1 every 5 years) ...........................$431.00 Pontic, cast predominantly base metal (limit 1 every 5 years) ...........................$404.00 Pontic, cast noble metal (limit 1 every 5 years) ...........................$420.00 Pontic, porcelain fused to high noble metal (limit 1 every 5 years) ...................$426.00 Pontic, porcelain fused to predominantly base metal (limit 1 every 5 years) ...........$393.00 Pontic, porcelain fused to noble metal (limit 1 every 5 years) ...................$415.00 Pontic, resin with high noble metal (limit 1 every 5 years) ...........................$420.00 Pontic, resin with predominantly base metal (limit 1 every 5 years) ...........$388.00 Pontic, resin with noble metal (limit 1 every 5 years) ...........................$400.00 Inlay - porcelain/ceramic two surfaces (limit 1 every 5 years) ...........................$355.00 Inlay - porcelain/ceramic three or more surfaces (limit 1 every 5 years) ...............$373.00

D6602

Inlay, cast high noble metal, two surfaces (limit 1 every 5 years) .........$380.00 Inlay, cast high noble metal, three or more surfaces (limit 1 every 5 years) .......$418.00 Inlay, cast predominantly base metal, two surfaces (limit 1 every 5 years) .........$372.00 Inlay, cast predominantly base metal, three or more surfaces (limit 1 every 5 years) ....$394.00 Inlay, cast noble metal, two surfaces (limit 1 every 5 years) ...........................$366.00 Inlay, cast noble metal, three or more surfaces (limit 1 every 5 years) ...............$406.00 Onlay - porcelain/ceramic two surfaces (limit 1 every 5 years) ...........................$386.00 Onlay - porcelain/ceramic three or more surfaces (limit 1 every 5 years) .......$403.00 Onlay, cast high noble metal, two surfaces (limit 1 every 5 years) .........$409.00 Onlay, cast high noble metal, three or more surfaces (limit 1 every 5 years) .......$448.00 Onlay, cast predominantly base metal, two surfaces (limit 1 every 5 years) .........$407.00 Onlay, cast high noble metal, three or more surfaces (limit 1 every 5 years) .......$426.00 Onlay, cast noble metal, two surfaces (limit 1 every 5 years) ...........................$399.00 Onlay, cast noble metal, three or more surfaces (limit 1 every 5 years) ...............$414.00 Crown, resin - with high noble metal (limit 1 every 5 years) ...........................$474.00 Crown, resin - with predominantly base metal (limit 1 every 5 years) ...........$450.00 Crown, resin with noble metal (limit 1 every 5 years) ...........................$458.00 Crown, porcelain/ceramic (limit 1 every 5 years) ...........................$499.00 Crown, porcelain fused to high noble metal - denture (limit 1 every 5 years) ......$486.00 Crown, porcelain fused to predominantly base metal (limit 1 every 5 years) ...........$453.00 Crown, porcelain fused to noble metal (limit 1 every 5 years) ...........................$464.00 Crown, 3/4 cast high noble metal .........$458.00 Crown, full cast high noble metal denture (limit 1 every 5 years) ................$469.00 Crown, full cast predominantly base metal - denture (limit 1 every 5 years) ......$445.00 Crown, full cast noble metal denture (limit 1 every 5 years) ................$461.00 Recement fixed partial denture (limit 1 every 5 years) .............................$57.00

D5410 D5411 D5421 D5422 D5510 D5520 D5610 D5620 D5630 D5640 D5650 D5660 D5710 D5711 D5720 D5721 D5730 D5731 D5740 D5741 D5750 D5751 D5760 D5761 D5850 D5851 D6210 D6211 D6212 D6240 D6241 D6242 D6250 D6251 D6252 D6600 D6601

ADVNAT4321 (04/06)

D6603 D6604 D6605 D6606 D6607 D6608 D6609 D6610 D6611 D6612 D6613 D6614 D6615 D6720 D6721 D6722 D6740 D6750 D6751 D6752 D6780 D6790 D6791 D6792 D6930

Current Dental Terminology © 2004 American Dental Association. All rights reserved.

PATIENT PAYS

ADVANTAGE - AVN1 Office Visit Co-pay General Provider $5 / Specialist Provider $15

schedule of benefits and subscriber copayments ADA CODE

PROCEDURE

D6970

Cast post & core add fix part dentur retainer (limit 1 every 5 years) ................$157.00 Prefab post & core add fix part dentur retain (limit 1 every 5 years) ..................$128.00 Core buildup for retainer including any pins (limit 1 every 5 years) ...........................$103.00 Extraction of coronal remnants, deciduous tooth .....................................$20.00 Extraction, erupted tooth or exposed root .........................................$26.00 Surgical removal of erupted tooth rqr elevflp & remv bone .........................$108.00 Removal of impacted tooth soft tissue .......$135.00 Removal of impacted tooth partially bony ......................................$179.00 Removal of impacted tooth completely bony ..................................$211.00 Removal of impacted tooth - completely bony - unusual surgical complications ......$265.00 Surgical removal of residual tooth roots ....$114.00 Alveoloplasty conjunc w/extractions per quadrant .......................................$125.00 Alveoloplasty conjunc xtract 1-3 teeth/spaces quad ...........................$97.00 Alveoloplasty not in conjunc w/extractions - quad ............................$181.00 Alveoloplasty not conjunc xtract 1-3 teeth/spaces quad .........................$153.00 Incision and drainage of abscess, intraoral soft tissue ................................$120.00 Incision and drainage of abscess, extraoral soft tissue ...............................$570.00 Frenulectomy separate procedure ............$111.00 Excision of hyperplastic tissue, per arch ....$272.00 Palliative treatment of dental pain minor procedure ....................................$45.00 IV conscious sedation/analgesia First 30 minutes ...................................$144.00 IV conscious sedation/analgesia each additional 15 minutes .....................$60.00 Consultation ..........................................$96.00 Occlusal adjustment, limited .....................$58.00 Occlusal adjustment, complete ...............$326.00

D6972 D6973 D7111 D7140 D7210 D7220 D7230 D7240 D7241 D7250 D7310 D7311 D7320 D7321 D7510 D7520 D7960 D7970 D9110 D9241 D9242 D9310 D9951 D9952

ADVNAT4321 (04/06)

PATIENT PAYS

ADA CODE

PROCEDURE

PATIENT PAYS

ORTHODONTICS D8070/D8080 Comprehensive Orthodontic Treatment of the transitional/adolescent dentition Children up to 19 years of age Up to 24 months of routine (full banded) orthodontic treatment for Class I and Class II cases Consultation ............................................$0.00 Evaluation .............................................$35.00 Records/Treatment Planning ...................$250.00 Orthodontic Treatment ........................$2,100.00 D8090

D8680

Comprehensive Orthodontic Treatment of the transitional adult dentition Adults 19 years of age and over Up to 24 months of routine (full banded) orthodontic treatment for Class I and Class II cases Consultation ............................................$0.00 Evaluation .............................................$35.00 Records/Treatment Planning ...................$250.00 Orthodontic Treatment ........................$2,300.00 Retention ............................................$450.00

NOTE 1. Your Participating General Dentist and Participating Specialist office visit co-payment amounts, if applicable, are shown on your I.D. card. Your office visit co-payment is applicable for all dates of service and is in addition to the co-payment amounts listed for covered services. 2. Co-payment amounts for listed procedures are applicable at either the Participating General Dentist or Participating Specialist. 3. Not all Participating Dentists perform all listed procedures, including amalgams. Please consult your dentist prior to treatment for availability of services. 4. Unlisted covered procedures are available at the Participating Dentist’s usual fee less 20%. 5. If you should need to see a specialist (i.e. Endodontist, Oral Surgeon, Periodontist, Pediatric Dentist), you may be referred by your Participating General Dentist, or you may refer yourself to any Participating Specialist.

Current Dental Terminology © 2004 American Dental Association. All rights reserved.

ADVANTAGE - AVN1 Office Visit Co-pay General Provider $5 / Specialist Provider $15

schedule of benefits and subscriber copayments

LIMITATIONS AND EXCLUSIONS 1. No service of any dentist other than a Participating General Dentist or Participating Specialist will be covered by Company, except out-of-area emergency care as provided in Section VIII, Paragraph B of the Certificate. 2. Whenever any Contributions or Copayments are delinquent, Member will not be entitled to receive Benefits, transfer Dental Facilities, or enjoy any of the other privileges of a Member in good standing. 3. Company does not provide coverage for the following services: a) Cost of hospitalization and pharmaceuticals, drugs or medications. b) Services which in the opinion of the Participating General Dentist or Participating Specialist are not Necessary Treatment to establish and/or maintain the Member’s oral health.

c) Any service that is not consistent with the normal and/or usual services provided by the Participating General Dentist or Participating Specialist or which in the opinion of the Participating General Dentist or Participating Specialist would endanger the health of the Member. d) Any service or procedure which the Participating General Dentist or Participating Specialist is unable to perform because of the general health or physical limitations of the Member. e) Any dental treatment started prior to the Member’s effective date for eligibility of benefits. f) Services for injuries and conditions which are paid or payable under Workers’ Compensation or Employers’ Liability laws. g) Treatment for cysts, neoplasms and malignancies. h) General anesthesia.

________________________________________________________________________________________________________________________________________________ CompBenefits Family of Companies CompBenefits CompBenefits Company CompBenefits Insurance Company CompBenefits Dental, Inc. CompBenefits of Alabama, Inc. CompBenefits of Georgia, Inc. American Dental Plan of North Carolina, Inc.

________________________________________________________________________________________________________________________________________________ ADVNAT4321 (04/06)

Current Dental Terminology © 2004 American Dental Association. All rights reserved.

frequently asked questions Q. What are CompBenefits Advantage dental plans? A. CompBenefits’ Advantage plans are network-based dental plans that emphasize prevention and cost containment. In order to receive services, you simply select any participating general dentist in CompBenefits’ Advantage network and make your appointment. You do not need to notify us of your choice. Advantage does not cover services (except emergency care) received from an out-of-network dentist. Q.

How do the plans work?

A. With CompBenefits’ Advantage plans, you do not have to pre-select a primary dentist. When you want dental services, simply select any general dentist from the CompBenefits’ Advantage network. Many preventive services are covered 100 percent after an office visit co-payment. Once you have paid your co-payment, you do not have to file any claim forms. For dental services that are not listed on your schedule of benefits, dentists will give you a 20 percent discount off their usual fees. You will pay your dentist directly, if applicable. Q.

How do I make appointments?

A. Making an appointment is easy. Simply call a participating dental office on or after the date you receive your certificate of coverage, and you may schedule an appointment. You do not have to notify us when you have selected your Advantage dentist. Q.

Do I need to select a participating dentist?

A. Yes, you will choose an Advantage network dentist, but you are welcome to change to another participating dentist at any time without notifying us. Q.

Is there any maximum coverage limitation?

A. No, there are no maximum coverage limitations. Q.

How do I pay for services?

A. You will be responsible for a co-payment, based on your schedule of benefits. Q.

What if I need a specialty dentist?

A. When treatment by a participating specialty dentist is required, you will pay a co-payment for procedures listed on your schedule of benefits.* For any other treatment, participating specialty dentists will give you a 20 percent discount off their usual fees. Q.

Can I go online to find out more about my plan or get assistance?

A. Yes. After you enroll, you can visit www.mycompbenefits.com to learn about your plan, to check your benefits, to use our Provider Locator, to send us an e-mail and more.

* Not applicable to ANV5 plans. Please refer to your schedule of benefits for details.

elite preferred What to expect from your dental plan: When you’re experiencing tooth pain, you can rest assured that your CompBenefits PPO dental insurance will give you the peace of mind that it will be there for you, helping with the expense of that trip to the dentist. CompBenefits’ fully insured PPO emphasizes preventive care – routine oral examinations, cleanings and x-rays – the simplest way to keep those nasty toothaches away. And you’ll get these benefits at an affordable price whether you choose a dentist from one of CompBenefits’ participating dental office locations or if you choose a dentist who is not in our network. If you need to file a claim, CompBenefits will reimburse you from our state-of-the-art claims system that pays claims quickly and correctly.

Get more out of your dental plan @ www.mycompbenefits.com Want to know the status of a claim? Need to find a dentist closer to you? You can do all of this and more at www.mycompbenefits.com. Registering for this service is simple and will give you access to your plan benefits, including your benefit information, claims status, a list of providers and the option to change your account information. Just a few clicks of the mouse, and you’ll be checking out your benefits in no time.

SSEP

Dental Plan of Choice

CompBenefits Insurance Company

Elite Preferred 700

_________________________________________________________________________________________________________________________

The network plan that offers maximum coverage with the cost advantages on a traditional indemnity plan.  FREEDOM TO CHOOSE ANY DENTIST Participants are free to select from a panel of participating dentists or seek care from any non-participating dentist.  VALUABLE SAVINGS FROM NETWORK DENTISTS Network dentists offer savings by agreeing to charge you based on negotiated maximum allowable contracted fee schedule. If you go to a non-participating dentist, the charged amount may be above that charged by a Participating Dentist.  NO BALANCE BILLING A participating dentist has agreed not to charge you any amount for services above the negotiated maximum allowable fee amount. When utilizing a non-participating dentist, you will be responsible for any extra amount charged by the dentist over the CompBenefits negotiated maximum and the customary charge of the dentist. 

EXTENSIVE NETWORK OF PARTICIPATING DENTISTS

Refer to your Provider Directory for a listing of participating dentists that offer services on a guaranteednegotiated fee schedule.

SUMMARY OF BENEFITS _____________________________________ Partial Listing of Covered Services

Type I Diagnostic & Preventive…100%……..…100% Oral Examination (once per six months) Prophylaxis (cleaning, once per six months) Topical Fluoride (children under 16, once per 12 months) Type II Basic Services……………. 80%…………80% Simple Restorative (amalgam, synthetic, or composite fillings) 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) Type III Major Services…………….50%……………50% Major Restorative (crowns/inlays/onlays) Endodontics (root canals) Periodontics (includes treatment of diseases of the gums) Tooth Extraction Emergency Palliative Treatment Bridge, Denture Repair Prosthetics (bridges and dentures)

 ACCESS TO INFORMATION Our toll-free Customer Care number at 1-(800)342-5209 has Customer Care Representatives who can provide the answers you need quickly and thoroughly.

Any way you add it up, CompBenefits really Is the benefits company of choice! 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.

In-Network Out-of-Network Reimbursements Reimbursements

MAXIMUM BENEFITS Insured Individual and Dependents Lifetime Type I, II, III……...…………………Unlimited……….Unlimited Calendar Year Type I, II, III…………………………….$1,000……..….$1,000 Deductible*** Type I…………………………….………None……..……None Type II, III….………………………………$50…….………$50

*Coverage based on Preferred Provider schedule of discounted 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.

Passive Voluntary PPO Passive Elite Choice 700-1 005CI700

Elite Preferred 700

CompBenefits Insurance Company

_________________________________________________________________________________________________________________________ MAJOR RESTORATIVE LIMITATIONS 8.

procedures performed by a Dentist who is a member of Your immediate family;

9.

any charges, including ancillary charges, made by a hospital, ambulatory surgical center, or similar facility;

10.

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;

11.

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;

12.

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;

13.

the care or treatment of an injury or sickness due to war or an act of war, declared or undeclared;

14.

treatment for cosmetic purposes. Facings on crowns or bridge units on molar teeth will always be considered cosmetic;

15.

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;

16.

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;

17.

a sickness for which the patient can receive benefits under a workers’ compensation act or similar law;

18.

an injury that arises out of or in the course of a job or employment for pay or profit;

19.

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

20.

orthodontic plan benefits for persons 19 years of age or older.

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;

4.

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;

5.

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

6.

the replacement of teeth up to the normal complement of 32.

EXCLUSIONS Benefits will not be paid for: 1.

2.

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;

PREDETERMINATION 3.

crowns, inlays, cast restorations, or other laboratory prepared restorations on teeth which may be restored with an amalgam or composite resin filling;

4.

appliances, inlays, cast restorations or other laboratory prepared restorations used primarily for the purpose of splinting;

5.

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;

6.

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;

7.

charges for travel time; transportation costs; or professional advice given on the phone;

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.

Passive Voluntary PPO Passive Elite Choice 700-1 005CI700

frequently asked questions Q. How does an Elite Preferred dental plan work? A. Under our PPO plans, you do not have to pre-select a primary dentist. When you want dental services, make your appointment with any licensed dentist. When you receive treatment from a CompBenefits PPO dentist, your costs will be reduced. Once services are performed, you or your dentist must file a claim form in order to receive reimbursement. Your claim will be paid based on your group’s schedule of benefits. The plan will pay a percentage of the eligible charges, up to the plan’s annual limit for benefits. Q.

How do I select an in-network dentist?

A. You may choose a participating PPO general dentist from our preferred provider directory available online at www.mycompbenefits.com. Participating general dentists in our network are conveniently located near your home or office. CompBenefits reviews each participating dentist’s credentials before he or she is selected to join our network. By using an in-network dentist, you will receive the maximum benefit of your plan. Q.

How do I select an out-of-network dentist?

A. By choosing a general dentist not included in the preferred provider list at www.mycompbenefits.com, you have selected an out-of-network provider. You will be charged the dentist’s usual fees for treatment. When you use an out-of-network dentist, your out-of-pocket costs will be typically greater than using an in-network dentist. Q.

When is predetermination required?

A. If planned treatment is going to cost more than $200, you should ask your dentist to file for predetermination of benefits prior to treatment. Predetermination is not necessary for emergency treatment. Q.

How does my bill get paid?

A. Each dentist bills separately. Your dentist may agree to file your insurance claim for you. If he or she does not, however, you may be required to pay the entire bill at time of service and will need to submit a claim to CompBenefits for your reimbursement. Your reimbursement will be based on whether you have met any applicable deductible or coinsurance amounts or not. All financial arrangements concerning payment are strictly between you and your dentist and should be determined prior to treatment. Q.

Where do I send my claims?

A. You can get a claim form from your Group Benefits Administrator, from CompBenefits’ Customer Care department or from our Web site, www.mycompbenefits.com. Mail your claim to: Humana Specialty Benefits P.O. Box 14283 Lexington, KY 40512-4283 Q.

Can I go online to find out more about my plan or get assistance?

A. Yes. After you enroll, you can visit www.mycompbenefits.com to learn about your plan, to check your benefits, to use our Provider Locator, to change your dentist selection, to send us an e-mail and more.

visioncare plan What to expect from your vision plan: Your eyesight is nothing to take for granted. It’s how we see a loved one’s face clearly or a beautiful sunset. But your sight can begin to deteriorate over a long period of time without your knowing there is a problem. As with any other important asset – like your home or car – wouldn’t you feel more at ease if you knew your routine eye care was covered by a company with decades experience helping people like you? With CompBenefits’ VisionCare Plan, you can take advantage of coverage you need for eye examinations and eyeglasses or contacts. You can also choose to take advantage of VisionCare Plan’s deep discount for LASIK surgery. And you won’t have to hunt hard to find a doctor close to your home or work. The VisionCare Plan network includes some 14,000 ophthalmologist and optometrist locations – one third of all private practitioners in the country. Yet, it doesn’t mean you can’t see an out-of-network doctor because VisionCare Plan offers benefits in-network or out-of-network. It’s your choice.

You’ll find what you need @ www.mycompbenefits.com CompBenefits has made understanding and accessing your VisionCare Plan benefits simple. Just take a few moments to register at www.mycompbenefits.com.

SSVCP

No claims to file! Just show your VisionCare Plan ID card

City of Plant City Open your eyes to high-quality vision care! The average family spends close to $600 each year on routine eye health care. Using CompBenefits’ VisionCare Plan, you will receive your routine eye health care with just a small copayment. CompBenefits’ VisionCare Plan provides benefits for covered:  Eye health examinations  Frames  Eyeglass Lenses  Contact Lenses Plus you will receive:  LASIK surgery discount  Preferred member pricing for other frame and lens options* When ordering from one of our network eye doctors, you will also receive in the year of your eye exam:  A 20% discount on a second pair of eyeglasses  A 15% discount on your contact lens fitting fee

SERVICE FREQUENCY Vision exam: Lenses: Frame:

COPAYMENTS

Once every 12 months Once every 12 months Once every 24 months

Exam: Materials:

$10 $15

SAVINGS! SEE THE DIFFERENCE You can save money two ways with VisionCare. First, the cost of plan services and materials is discounted and prepaid. So except for any co-payments, you have no out-of-pocket expenses for covered services and supplies when you use one of our network doctors. Second, your coverage costs are deducted from your pay before any federal income or FICA taxes are taken out. This makes your taxable wage base lower, so you would pay less tax. Here’s an example of how the plan helps you save over the course of a year:

If You Get:

You Pay: VisionCare Doctor

Eye exam Frame (designer style) Lenses: Bifocal Option (pink tint #1 or #2) Co-payments: $10 exam/$15 materials Premium ($5.20 monthly x 12)

Typical Retail

.00 .00 .00 .00

$ 85.00 120.00 100.00 15.00

$ 25.00 +62.40

.00 .00

87.40

$ 320.00

Pre-tax savings (assuming 15% tax bracket & 7.65% FICA)

- 17.88

+ .00

Total Cost

$69.52

$ 320.00

YOUR TOTAL SAVINGS THROUGH VISIONCARE: 78% OFF RETAIL In this example, you would have saved $250.48 in vision care costs with VisionCare Plan. Keep in mind, however, that your actual savings will depend on your plan allowances, your actual premium, the doctors and materials you select, and your own tax situation. * This is not a schedule of maximum benefits. For example, the plan covers frames based on the manufacturer’s wholesale price guide. So while the retail price of a covered frame may vary among plan doctors, the value of your covered frame stays the same. Typically, the wholesale frame allowance is equivalent to a retail price of $80-150. You may be required to pay extra only if you choose a frame that exceeds the covered wholesale price.

Maximum Allowances

Participating Doctor (After copayments/ Up to plan limits)

* This allowance is paid with the same frequency as lenses, in place of all other benefits.

Single

Paid in full

Bifocal

Paid in full

** Medically necessary (prior authorization required) is defined as 1) following cataract surgery w/o intraocular lens; 2) correction of extreme visual acuity problems not correctable with glasses; 3) anisometropia greater than 5.00 diopters and asthenopia or diplopia, with spectacles; 4) Keratoconus; or 5) monocular aphakia and/or binocular aphakia where the doctor certifies contact lenses are medically necessary for safety and rehabilitation to a productive life.

Trifocal

Paid in full

*** Plan members must first contact CompBenefits for a list of providers and to receive a Refractive Care ID card.

Lenticular

Paid in full

Eye Exam

Paid in full

Lenses (per pair)

Contact Lenses Elective (fitting, follow-up & lenses)

$105*

Medically necessary**

Paid in full

Frame

$45 wholesale

This schedule shows only a few of the covered procedures. Please see your Benefit Administrator for a complete schedule. This schedule is intended for comparison purposes only. The benefits of each plan will be determined by the contract. For a complete listing of benefits and exclusions and limitations, please reference your certificate of coverage. Out-of-network benefits apply under the VisionCare Plan, but benefits are higher when a participating doctor is utilized. Limitations and Exclusions apply.

HOW DOES VISIONCARE PLAN WORK? Members simply select any in-network optometrist or ophthalmologist and schedule an appointment. You can locate a provider in your area by accessing the current directory online at www.humanavisioncare.com. The Plan is simple to use. Select a doctor from our provider directory and call for an appointment. At the time of your appointment, present your ID Card to the participating provider. Members will pay only their co-payments and for any extra cosmetic options selected. There are no additional forms to complete or claims to file. Members can also choose an out-of-network provider. In this case, you will pay the doctor at the time of the visit and submit receipts to Compbenefits for reimbursement.

CAN I GET CONTACTS INSTEAD OF LENSES? Yes. If you prefer contacts instead of glasses, your vision exam is covered-in-full with your exam co-payment and VisionCare Plan provides a generous allowance of $105.00 to be applied towards your fitting and follow-up fees as well as materials costs. The Contact Lens allowance in LIEU OF THE LENS / FRAME BENEFIT and is provided with the same frequency as your lens benefit.

HOW DO I GET FURTHER QUESTIONS ANSWERED? You may contact CompBenefits Customer Care Department with any questions or concerns at: 1-866-537-0229, Monday – Thursday 8am-8pm; and Friday 8am-6pm EST. or locate us on the web at www.humanavisioncare.com.

frequently asked questions Q. What are CompBenefits’ VisionCare Plans? A. CompBenefits’ VisionCare Plans are network-based vision plans that emphasize high quality routine eye health care from independent eye care professionals. Services and materials are provided on a pre-paid basis, and the plans pay network doctors directly. VisionCare Plan members can also use non-network doctors if they wish. Q.

How does VisionCare Plan work?

A. Members simply select any in-network optometrist or ophthalmologist and make their appointments. At the time of the appointment, members pay only their co-payments and for any extra cosmetic options selected. There are no forms to complete or claims to file. Members can also choose an out-of-network provider. In this case, they pay their doctor at the time of the visit and submit receipts to CompBenefits for reimbursement. Benefits are paid according to a reimbursement schedule. Q.

Are there any limitations to my vision benefit?

A. Yes, there are a few. Oversized lenses, when prescribed, may be covered only when patient’s face size indicates they are necessary. Blended and progressive lenses are not normally required for visual welfare and are generally excluded. Elective or cosmetic items such as photochromic lenses, fashion color-coated lenses and sun lenses are not normally covered. Q.

Does VisionCare Plan exclude anything?

A. Yes, some items and services are excluded. • Orthoptics or vision training, subnormal vision aids or plano (non-prescription) lenses • Replacement of lost or broken lenses, except at the regularly-scheduled plan intervals • Medical or surgical treatment of the eyes • Care provided through or required by any government agency or program,including Workers’ Compensation or similar law Q.

What do I need to access my benefits?

A. It’s simple. Just take your VisionCare Plan ID card to your eye doctor, and he or she will file your claim for you. Q.

Can I go online to find out more about my plan or get assistance?

A. Yes. You can visit www.mycompbenefits.com to learn about your plan, to check your benefits, to use our Provider Locator, to send us an e-mail and more.

HumanaVision Lasik

Reduced fees Lasik procedures are available if you are nearsighted or have astigmatism and wear glasses or contacts.2 We have contracted with many well-known facilities and eye doctors to offer these procedures at substantially reduced fees. You can take advantage of these low fees when procedures are done by network providers. The network locations listed below offer the following prices (per eye):

Conventional / Traditional Opening doors to better vision for thousands of people – with affordable Lasik procedures1 Network doctors can help you understand these new procedures and provide access to our network

TLC

$895

888-358-3937

Custom $1,295

$1,895*

(designated locations only)

LasikPlus 866-757-8082

QualSight LASIK 855-456-2020

of Lasik providers.

$6953*

LasikPlus free enhancements for 1 year

$895

QualSight free enhancements for 1 year

$1,395*

LasikPlus free enhancements for life

$1,295

with QualSight Lifetime Assurance Plan

$1,895*

LasikPlus free enhancements for life

$1,320

$1,995*

with QualSight Lifetime Assurance Plan

*with IntraLaseTM

You can also use independent Lasik provider network doctors to receive a 10% discount from usual and customary prices and pay no more than $1,800 per eye for Conventional Lasik and $2,300 per eye for Custom Lasik.

Easy access to service

Laser-assisted in-situ keratomileusis

During your comprehensive eye health examination, your doctor can determine if you are a candidate for Lasik. If you qualify, the doctor can also make arrangements for the procedure with one of the centers that participates in this program.

1

If qualified as a Lasik candidate by the network doctor

2

Nearsighted better than -2 with astigmatism better than -1 and other restrictions apply

3

The Lasik program is a discount only for HumanaVision members and is not a covered benefit. Insured by Humana Insurance Company or CompBenefits Insurance Company, or The Dental Concern, Inc. GN-52223-HV 2/11

Your HumanaVision ID card verifies your eligibility for Lasik discounts. You can obtain a list of providers from our website, HumanaVisionCare.com or by calling a Customer Care Specialist at 866-537-0229. This discount cannot be combined with any other discount or promotional offer. The HumanaVision Lasik program is not affiliated with any medical or health plan.

See the difference a bigger, better HumanaVision network can make for you. HumanaVision VCP has a newly expanded network. Choose from more than 35,000 participating optometrist, ophthalmologist, and national retail locations, including LensCrafters, Pearle Vision, Sears Optical, Target Optical, and JCPenney.

HumanaVision offers: • Cost-Savings — Your benefits for eyewear apply at even more HumanaVision provider locations. And you’ll pay the same cost for frames no matter where you go. • Choice — You now have access to exclusive lines of designer frames, such as Dolce & Gabbana®, Oakley ®, Prada®, Ralph Lauren®, and Ray-Ban®. • Convenience — Take care of eye exams and frames all in one visit. Many locations offer night and weekend appointments to fit your schedule.

Start enjoying these benefits today. Be on the lookout for enrollment session information or visit: HumanaVisionCare.com

Finding a provider is easy. Call Customer Care at 1-866-537-0229 or go to HumanaVisionCare.com.

To offer the widest choice, HumanaVision also includes independent optometrists and ophthalmologists located throughout the country. For a complete listing of providers near you, visit humanavisioncare.com. Looking for a great pair of glasses to fit your unique personality and lifestyle? LensCrafters is the right place for you. You can choose from a wide selection of fashion frames including the latest designers like Prada®, Versace®, Burberry ®, and Dolce & Gabbana®. Add the latest lens technology for that great pair of glasses. More than 850 locations nationwide. Visit lenscrafters.com for the latest styles and trends and your nearest location. Pearle Vision continues the legacy of personalized eye care that Dr. Stanley Pearle started over 45 years ago. Combine that with a great selection of frames and lens options and over 750 convenient locations to make Pearle Vision a great place for your family’s eye care. Go to pearlevision.com to learn more. Sears Optical has been helping families see better and look great at the right price for over 45 years. Everything you love and trust about Sears is what you’ll find at Sears Optical — professional service, stylish selection of frames and the latest contact lens advancements, quality, and great value for the entire family. Satisfaction guaranteed or your money back. More than 850 Sears Optical locations are conveniently located nationwide. Visit searsoptical.com for one near you. Your eyes. Your style. Target Optical provides fashion for less than you’ve come to expect from Target, with the care of a professional independent doctor of optometry. You can choose from a huge selection of frames and sunglasses, including brands like Mossimo®, Vogue®, and Versus®. The latest contact lens technology is also available at affordable prices. Visit target.com for more information. JCPenney Optical is a full-service optical center conveniently located in more than 350 JCPenney department stores. Choose from hundreds of frames that will inspire and reflect your lifestyle, including exclusive designer brands such as Bisou Bisou®, a.n.a.®, Liz & Co.®, and Arizona®. JCPenney Optical also offers eye exams, contact lenses, and non-prescription sunwear to meet all of your eyewear needs.

Insured by Humana Insurance Company, CompBenefits Insurance Company, CompBenefits of HumanaDental Insurance Company, CompBenefits Company, or The Dental Concern, Inc. GCA0AV3HH 4/11

Dental Claim Form Check One: ❏ Dentist’s pre-treatment estimate ❏ Dentist’s statement of actual services

P A T I E N T

C O V E R A G E

I N F O R M A T I O N

Humana Specialty Benefits P.O. Box 14283 Lexington, KY 40512-4283 2. Relationship to employee

1. Patient name first

m.i.

last

❏ self

MM

DD

MM

12-a. Name and address of carrier(s)

11. Is patient covered by another dental plan? ❏ yes ❏ no If yes, complete 12-a.

City

DD

10. Group number

YYYY

12-b. Group no.(s)

13. Name and address of other employer(s)

Is patient covered by a medical plan? ❏ yes ❏ no 14-a. Employee/subscriber name (if different than patient’s)

14-b. Employee/subscriber soc. sec. or I.D. #

Signed (Patient, or parent if minor)

14-c. Employee/subscriber birthdate MM

Date

DD

25. Is treatment result of auto accident?

City, State, Zip

21. First visit date current series

8 9 10 6 7 11

Other

20. Dentist phone no.

Date No Yes If yes, enter brief description and dates.

23. Radiographs or models enclosed?

No

Yes

How Many?

(If no, reason for replacement)

29. Is treatment for orthodontics?

If services already commenced enter:

30. Examination and treatment plan _ List in order from tooth no. 1 through tooth no. 32 _ Use charting system shown. Date service performed Mo. Day Year

Procedure number

12 13 14 15 16 PERMANENT

LEFT

17 32 K T LINGUAL L 18 31 S 19 M R 30 Q P ON 20 29 21 28 22 27 26 25 24 23 FACIAL

31. Remarks for unusual services

I hereby certify that the procedures as indicated by date have been completed and that the fees submitted are the actual fees I have charged and intend to collect for those procedures. Signed (Treating Dentist)

❏ other ______________________

27. If prosthesis, is this initial placement?

Tooth Surface Description of service # or (including x-rays, prophylaxis, materials used, etc.) Letter

PRIMARY

LOWER UPPER

19. Dentist license no.

22. Place of treatment Office Hosp. ECF

FACIAL

RIGHT

❏ parent

❏ spouse

26. Other accident?

18. Dentist Soc. Sec. or T.I.N.

E D FG C H B LINGUAL I J A

❏ self

Signed (Insured person)

17. Address where payment should be remitted

4 3 2 1

15. Relationship to beneficiary



24. Is treatment result of occupational illness or injury?

5

YYYY

I hereby authorize payment of the dental benefits otherwise payable to me directly to the below named dental entity.

16. Name of Billing Dentist or Dental Entity

Identify missing teeth with “x”



School

YYYY

7. Employee/subscriber 8. Employee/subscriber 9. Employer (company) birthdate soc. sec. or I.D. # name and address

6. Employee/subscriber name and mailing address



D E N T I S T

5. If full time student

4. Patient birthdate

❏ spouse ❏ other ____________

I have reviewed the following treatment plan. I authorize release of any information relating to this claim. I understand that I am responsible for all costs of dental treatment.

B I L L I N G

3. Sex m f

❏ child

License Number

Date

Full mouth radiographs and complete mouth charting must accompany claim form for major restorative and/or periodontal therapy. Any person who knowingly and with intent to defraud or deceive any insurer, files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree.

Total Fee Charged

Max Allowable Deductible Carrier % Carrier Pays Patient Pays

Fee

28. Date of prior placement

Date appliances placed

For administrative use only

Mos. treatment remaining

Benefits Enrollment Form Group Name:

City of Plant City

Please complete the following information: Social Security No.

Last Name

First

Home Address

Middle

Gender

Home Phone

City

State

ZIP Code

Date of Birth

Business Phone

Facility Number

List All Your Eligible Dependents That Are To Be Covered First

MI

Last

Sex

Facility Number

Birth Date

Spouse:

M

F

/

/

Child:

M

F

/

/

Child:

M

F

/

/

Child:

M

F

/

/

Child:

M

F

/

/

Child:

M

F

/

/

Child:

M

F

/

/

Effective Date

PLEASE CHECK YOUR CHOICE

Plan Code

Group Number

Dental Plan AVN1 Group# 7274

Your E-mail Address

Dental Plan EP700 Group# 8274

Agent Code

Vision Plan Group# VS3122

Monthly Rates

Employee Only Employee + One Employee + Family

I wish to enroll in the plan indicated above as offered through my employer. I understand that this is a minimum one (1) year contract. I hereby authorize my employer to deduct all applicable contribution amounts from my salary or other compensation for the plan year, and for future renewal period(s). I understand that such contribution rate is subject to change on the anniversary date of the plan. I hereby represent that all information furnished by me hereon is true and complete to the best of my knowledge. Signature: X

Date:

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