Download deductible - Atlas Resources

ATLAS RESOURCES
GROUP # 10023
PPO Schedule Sandia
SUMMARY OF DENTAL BENEFITS
Plan B
In Network
Out of Network
PREVENTIVE SERVICES
EXAMS – one in any six consecutive month period
X-RAYS – bitewings, once in any consecutive 12-month period,
full mouth series once every 60-month period
TEETH CLEANINGS – (Prophylaxis) one treatment in any consecutive
six-month period
EMERGENCY PALLIATIVE TREATMENT
TOPICAL APPLICATION OF FLUORIDE – only for children under
15 in any consecutive six-month period
SEALANTS – coverage up to age 16 for permanent molars only
100%
100%
BASIC SERVICES
RESTORATIVE – amalgam, composite resin, and plastic
restorations, and stainless steel crowns
GENERAL ANESTHESIA – general anesthesia and IV sedation
when administered by a dentist for a covered oral surgery procedure
ENDODONTICS – treatment of root pulp, root canal
ORAL SURGERY- extractions and other surgical dental
procedures (includes pre and post operative care.)
90%
80%
MAJOR SERVICES
PERIODONTICS – treatment of gums and bones supporting teeth.
Periodontal cleaning.
CROWNS AND CAST RESTORATIONS – only when teeth cannot be
restored with amalgam, composite resin, or plastic fillings
PROSTHODONTICS – procedures to construct or repair fixed bridges,
partial or complete dentures. There is a 12- month waiting period for major
services for new employees.
60%
50%
ORTHODONTICS
50% up to $375
Lifetime maximum
Coverage for children up to age 19
Treatment to correct poorly aligned teeth and jaws which significantly interferes with function.
DEDUCTIBLE
In Network
$0
$0
Out Network
$ 25 individual
$ 75 family
The DEDUCTIBLE is the amount of money that each enrolled person must pay before benefits will be paid under
this program for covered dental benefits for BASIC and MAJOR SERVICES. The deductible is NOT applied to
PREVENTIVE or ORTHODONTIC SERVICES. The deductible is applied on a contract year basis. Contract year is
March 1st to February 28th.
This is a summary of the Atlas Resources dental benefit plan. All benefits are subject to the contract limitations and
exclusions. For a more detailed description of benefits please refer to your Certificate of Coverage Handbook. With the
DentalSource In Network Option, DentalSource pays for Dental Services based on the Preferred Provider Schedule of
Fees. Out of network fees are based upon predetermined Usual, Customary, and Reasonable Charges.
MAXIMUM
$ 500.00 PER ENROLLED PERSON – (non-orthodontic)
$ 375.00 lifetime for orthodontic services
The MAXIMUM is the total dollar amount that will be paid by this program toward covered dental benefits for
enrolled persons. The MAXIMUM is applied on a contract year basis. Contract Year is March 1st to February 28th.
FREEDOM OF CHOICE
You choose the dentist – worldwide. You may visit a specialist without referrals. You may change your dentist
without notifying DentalSource Administrators.
Participating Dentists:
DentalSource contracted dentists will:
1. File claim forms for you. Members are responsible for signing the claim form and verifying accuracy of
patient/member information.
2. Accept payment directly from DentalSource. DentalSource will pay the benefit coverage portion
directly to the dentist. The non-covered portion is the responsibility of the member.
3. Participating dentists have approved fees that provide maximum dental savings. The dentist will not bill
more than the allowable contracted charges. This means the procedures will be paid at the percentage
coverage stated on this benefit sheet.
Non-Participating Dentists:
Non-contracted dentists:
1. Member will receive reimbursement for the allowable amount as determined by DentalSource Inc.
2. Member is responsible for any charge over the allowable amount paid by DentalSource.
3. Member may use any licensed Dentist.
PRE-EXISTING CONDITIONS – The plan will not pay for initial prosthetic placement for congenitally missing teeth or for
a tooth that has been removed before the patient is covered under the Atlas Resources program.
OPTIONAL SERVICES – DentalSource allows the least expensive American Dental Association (ADA) accepted
treatment. For example: DentalSource allows and pays for silver (amalgam) fillings on posterior teeth. If you
choose a composite resin, you will pay for the difference in price.
PRE-TREATMENT ESTIMATE (PRE-DETERMINATION)
It is STRONGLY suggested that you get a pre-treatment estimate of benefits for all MAJOR SERVICES or services
amounting to $200 or more. A pre-treatment estimate will ensure that you know the procedure you are
contemplating having done is covered under this benefit plan as well as what your financial responsibility will be. A pretreatment estimate is not a determination of the need for treatment, only a determination of contracted coverage.
ELIGIBILITY – You, your spouse and your unmarried dependent children to age 25 are eligible as defined by your Group
Contract.
WAITING PERIOD – New employees under the Atlas Resources group dental plan have a 12-month waiting period for
major services unless this plan is replacing another dental plan that has been in force for 12 or more months.
LIMITATIONS & EXCLUSIONS
Prophylaxis limited to one in any six-month period. Fluoride limited to persons under 14 years of age. Sealants
limited to the un-restored permanent molars of covered persons under age 16. No coverage for precision
attachments, appliance or prosthetic device less than 10 years old or if lost or stolen. TMJ and cosmetic
procedures are not covered.
MAIL CLAIMS TO:
Dental Administrators, PO Box 11569,Albuquerque NM 87192
Albuquerque Number 237-1501
Outside Albuquerque 1-888-862-8659 Web Site: dentalsource.com
This summary of the group dental program is subject to the provisions of the group dental contract and cannot modify or
affect the group dental contract in any way, nor shall you accrue any rights because of any statement in or omission from
this summary.