Sandia Plan Join our Sandia Plan today and enjoy on-the-spot savings from 20% to 60% on more than 250 dental procedures like exams, cleanings,

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1 Sandia Plan Join our Sandia Plan today and enjoy on-the-spot savings from 20% to 60% on more than 250 dental procedures like exams, cleanings, fillings, root canals, crowns, and even braces.

2 The Sandia Plan is an economic dental plan option. Members obtain dental services from our ever expanding panel of participating dentists. Members enjoy guaranteed low, pre-set fees on almost all types of dental work. Savings from 20% 60% are available for most basic and major dental services. Plan discounts are designed to encourage proper dental care by promoting early detection and regular dental health maintenance.

3 Sandia Plan Need help choosing a dental plan that is right for you? Our Sandia Dental Plan is a referral dental plan that is an alternative to dental insurance for individuals and families. Individual dental care without paperwork hassles and annual limits: You can visit dentists near your home and work Ideal for students, professionals, retirees & self-employed Save on check-ups, cleanings, fillings, root canals, crowns, and more Entire families large and small save all year long: It easy to protect your family s dental health and save money Receive savings from pediatric dentists & orthodontists Save on exams, cleanings, fillings, and even braces

4 What is the cost? Monthly Annual Individual $6.50 $69.00 Individual + 1 Dependent $11.25 $ Individual + Family $16.50 $ When using Sandia Plan dentists, compare your savings for these services: With no coverage you pay: With BenefitSource you pay: YOU SAVE: Consultation $75 No Charge $75 Diagnostic Casts $87 $65 $22 Exam (Initial) $80 $43 $37 Bitewing 4 Films X-rays $53 $35 $18 Adult Teeth Cleaning $88 $60 $28 Child Teeth Cleaning $60 $42 $18 Silver Filling 1 surf. $120 $76 $44 Silver Filling 3 surf. $162 $119 $43 Resin Filling White, 1 surf. $145 $91 $54 Resin Filling White, 2 surf. $163 $114 $49 Root Canal Molar $940 $725 $215 Crown High Noble $930 $765 $165 Extraction, Routine $125 $73 $52 Denture Complete Upper or Lower $1,525 $1,012 $513 Denture Partial Upper or Lower $1,125 $951 $174 Braces (Child) $6,000 $5,028 $972 This is an abbreviated schedule of dental fees. A complete fee schedule will be mailed with your ID card once enrollment is processed. You may also visit our web site: to review the complete fee schedule.

5 Who are your dentists? BenefitSource has more than 1,400 dentists statewide for Sandia Plan members. Visit our website: for the most current list of Sandia Plan providers, or call our office. How do I join? Complete the attached Enrollment/Authorization form and return it to our office. Don t forget to select your Sandia Plan dental office. What are my payment options? Annual payment: You may pay the annual membership fee by check, money order, MasterCard, Visa or Discover Cards. Monthly payment: You may pay monthly with an electronic fund transfer payment. To do this, complete the Enrollment/Authorization form and submit this with a check made out to BenefitSource for the first month s payment. You must also provide a voided check from the checking or savings account you wish to have fees drafted. Each month, the premium will be automatically drafted from your bank account between the 23rd and 28th of the month for the next month s coverage. Join our Sandia 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.

6 For more information, please contact us at: 1804 Juan Tabo NE, Suite A, Albuquerque, NM benefitsource.org

7 Sandia Plan Enrollment/Authorization Form PLEASE PRINT CLEARLY Social Security Number Date of Birth Sex / / M F Name: Last, First, Middle Initial Coverage Effective Date Agent / / Address: Street, City, State, Zip Dental Office Selected 1/17 Address Home Phone Work Phone Covered Dependents Name: Last, First, Middle Initial Relationship Sex Date of Birth PLEASE CHOOSE YOUR PAYMENT OPTION Annual Payment Please check one: Check VISA MasterCard Discover Credit Card # Expiration Date CVV # Draft Authorization/Membership Agreement Unless I have elected annual payment, I hereby authorize BenefitSource to charge my account each month the applicable membership fee to be credited to my account with BenefitSource. This authority is to remain in full force and effect until I notify BenefitSource in writing of its termination (My Bank is authorized to make corrections should any be necessary). I have read and understand the terms and conditions of this authorization. I hereby authorize the release of my dental records to BenefitSource for use in a quality review program. Signature Date Monthly Bank Draft: Surepay Electronic Funds Transfer Payment Please charge my account monthly: Checking Savings Routing # Account #

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