Download Orthodontic Edge

Orthodontic
Edge Plan
Getting braces has become very expensive.
Join our Orthodontic Edge plan today for
the low annual fee of $35 per person
and enjoy on the spot savings of 10% to
20% on fees related to orthodontic care,
including the necessary appliances.
Join our Orthodontic Edge
Plan today and eliminate
the hassles of deductibles,
claim forms, and prior
authorization requirements.
Also, there are no benefit
limits, no waiting periods,
and no exclusions for
preexisting conditions.
Orthodontic Edge
Need help with reducing the cost of
expensive orthodontic care for you
or your children? Orthodontic Edge is
a referral plan that provides discounted
fees when visiting BenefitSource
Sandia Plan Participating Orthodontic
Providers. This plan is ideal for those
who have basic dental coverage, but
need additional benefits specifically for
orthodontic care (braces).
Individual orthodontic care
without hassles or annual
limits:
• Save on all exams related to
orthodontic care
• Save on most appliances, including
repairs or replacement of lost
appliances
• No age limits, care for children
and adults included
• No waiting period or benefit
maximums
When using our Sandia Plan dental
providers, you pay directly to the
orthodontic office:
ADA
Procedure Name
8010
Limited Ortho – Primary Dentition
Member
Pays
$2,006
8020 Limited Ortho – Transitional Dentition
$2,298
8030 Limited Ortho – Adolescent Dentition
$2,752
8040 Limited Ortho – Adult Dentition
$3,048
8050 Interceptive Ortho – Primary Dentition
$2,640
8060 Interceptive Ortho – Transitional Dentition
$2,835
8070 Comprehensive Ortho – Transitional Dentition
$4,898
8080 Comprehensive Ortho – Adolescent Dentition
$5,028
8090 Comprehensive Ortho – Adult Dentition
$5,555
8210
Removable Appliance Therapy
$ 705
8220 Fixed Appliance Therapy
$ 833
8670 Periodic Orthodontic Visit (contract)
$ 246
8680 Retention Removal of Appliances
$ 647
8690 Orthodontic Treatment (alternate to contract)
$ 150
8691 Appliance Repair
$ 194
8692 Lost or Broken Retainer
$ 96
8693 Rebonding or Repair of Fixed Retainer
$ 150
0322 Tomographic Survey *
$ 170
0330 Panoramic Film *
$ 65
0340 Cephalometric Film *
$ 68
0350 Oral Facial Images *
$ 52
0470 Diagnostic Costs *
$ 65
* Included in total Orthodontic fee.
What is the membership cost?
The low annual membership fee is just $35 per person!
Who are the Orthodontists?
BenefitSource has many Participating Orthodontists
statewide for members. Visit our website: www.
benefitsource.org for the most current list of Sandia
Plan Participating Orthodontists.
How do I join?
Complete the attached Enrollment/Authorization
form and return it to our office. Don’t forget to select
your Sandia Plan Orthodontic office. Applications
received by 23rd of the month will be effective 1st of
the following month.
What are my payment options?
The low annual membership fee may be made by check,
money order, MasterCard, Visa or Discover Card.
What if I’m currently in Orthodontic
Treatment?
This plan is designed for those just beginning
Orthodontic treatment. It does not cover mid-treatment
takeover.
Orthodontic Edge Plan Enrollment/Authorization Form
P L E A S E P R I N T C L E A R LY
F
/
Sandia Orthodontist Selected
/
Social Security Number
Date of Birth
Sex
/
/
M
Name: Last, First, Middle Initial
Address: Street, City, State, Zip Home Phone
 Check  VISA  MasterCard  Discover
Coverage Effective Date E-Mail Address
Please check one:
P L E A S E C H O O S E Y O U R PAY M E N T O P T I O N
 Annual Payment
Credit Card #______________________________________________________________
Expiration Date___________________________________ CVV #______________________
Agent
Work Phone
1/14
For more information, please contact us at:
1804 Juan Tabo NE, Suite A, Albuquerque, NM 87112
888 862 8659 | 505 237 1501
benefitsource.org