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GROUP DENTAL PLAN IV-E
ARKANSAS TECH UNIVERSITY
Effective 1/1/2017
Benefits
Coverage (%)
A - Diagnostic & Preventive Services:
Routine Periodic Exams
X-Rays
Fluoride Treatment
Prophylaxis (Cleaning)
Sealants
100%
(no deductible)
B - Basic Services:
80%
Fillings-(includes Composite Resin Restorations on Posterior (after deductible)
Teeth)
Endodontics (Root Canals)
Simple Extractions
Nonsurgical Periodontics (Gum Treatment)
Oral Surgery (Surgical Extractions)
C - Major Services:
Inlays, Onlays,
Crowns & Bridges
Dentures, Full or Partial
Surgical Periodontics
Implants
50%
(after deductible)
D - Orthodontic Services:
Diagnostic, Active, Retention Treatment
Eligible Dependent Children Under Age 19
50%
(after deductible)
$ 1,000 Lifetime Max
Deductibles & Annual Maximum:
$50 Per Calendar Year Deductible Per Member (3X Family Max.) – Waived on Diagnostic &
Preventive Services
$1,000 Per Calendar Year Maximum Per Member
Includes Calendar-Year Maximum Rollover Benefit – this feature allows members to
rollover a portion of their unused calendar-year maximum for future use.
Dependents are covered to age 26
This outline is only a guide. This description is not legally binding. The controlling terms of the Plan are set forth in the
Benefit Certificate incorporated in the Arkansas Blue Cross and Blue Shield Group Insurance Contract. Any
discrepancies between this outline and the Benefit Certificate will be resolved in favor of the Benefit Certificate.
Customer Service toll free#: 1-888-223-4999
To locate a dental provider: www.arkansasbluecross.com
ARKANSAS BLUE CROSS AND BLUE SHIELD
GROUP DENTAL INSURANCE POLICY
Arkansas Tech University
Calendar Year Maximum Rollover Benefit
We understand oral health is a critical part of overall health. That’s why we offer a dental
insurance plan that allows you to “rollover” a portion of your unused dental benefits from year to
year.
The Rollover Benefit allows you to accumulate benefit dollars to help offset higher out-of-pocket
costs for complex procedures.
This benefit applies automatically if you:
• Receive at least one covered dental service during the calendar year
• Are an active member of the plan on December 31
• Your total paid claims for the year do not exceed $500 (the Yearly Threshold Amount)
• Your total Rollover account balance has not exceeded $1,000 (the Accumulated Rollover
Maximum)
How Maximum Rollover Works
If we do not pay out more than $500 in claims on your behalf during a Calendar Year, your
Calendar Year Maximum of $1000 for the next year will increase by $350, for a total of $1350.
We will add $350 to your Rollover account balance every year you meet the requirements listed
above up to a maximum of $1,000. That is the most money you can accumulate in your Rollover
account at any time. This amount is called the Accumulated Rollover Maximum.
Frequently Asked Questions
Q. Are any expenses not included when determining the amount of claims paid during a Calendar
Year?
A. Yes, claims for Orthodontia services, deductibles, coinsurance, co-pays, non-covered amounts,
charges billed by non-par providers which exceed the allowed amount for the services rendered
or balance billing amounts you may owe are not included in the total paid claims amount
(Yearly Threshold Amount) when determining your eligibility to rollover dollars to the next
Calendar Year.
Q. When paying a claim, will the Calendar Year Maximum dollars or the Maximum Rollover dollars
be used first?
A. The Calendar Year Maximum dollars will be used first and then the Maximum Rollover dollars.
Q. Will the Maximum Rollover dollars be affected if claims have not been received by the last day
of the calendar year?
A. If claims for services covered in the prior year are received after February 15; the Rollover
calculation will be adjusted.
ROFlyer 10/09
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