ADA CODE PROCEDURE PATIENT PAYS ADA CODE PROCEDURE PATIENT PAYS APPOINTMENTS
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1 PRESTIGE 25 Schedule of Benefits and Subscriber Copayments ADA CODE PROCEDURE PATIENT PAYS ADA CODE PROCEDURE PATIENT PAYS APPOINTMENTS 5130 Immediate maxillary (upper)...$ Office visit (normal hours)...$ Immediate mandibular (lower)...$ Emergency visit (regular hours)...$20.00 Partial dentures (includes adjustments within 30 days) 9440 Emergency visit (after hours)...$ /5212 Maxillary/mandibular partial - resin base 0999 Broken appointments (without 24 hr notice, per 15 min)... $10.00 Maximum $40 per broken appointment. No charge will be made due to emergencies. (with 2 clasps)...$ /5214 Maxillary/mandibular partial - cast metal with resin base (with 2 clasps)...$ /5411 Adjust complete - maxillary/mandibular...$15.00 DIAGNOSTIC 5421/5422 Adjust partial denture - maxillary/mandibular...$ /0150/0160 Oral evaluation...no CHARGE 5999 Additional clasps...$ Periodic oral evaluation...no CHARGE REPAIRS TO PROSTHETICS 0470 Diagnostic casts (study models)...no CHARGE 5510/5610 Repair broken resin denture base...$20.00 * 0999 Diagnosis and treatment plan presentation... NO CHARGE 5520/5640 Replace missing or broken teeth (each tooth)...$15.00 * 9310 Consultation (second opinion) as provided 5520/5640 Each additional tooth...$15.00 * by participating dentist...$ Repair or replace broken clasp...$20.00 * 0460 Pulp vitality tests...no CHARGE 5650 Add tooth to existing partial denture...$30.00 * RADIOGRAPHS (X-rays) 5850/5851 Tissue conditioning...$ Intraoral - complete series...no CHARGE 5730/5731/5740/5741 Relining (chairside)...$ Intraoral - periapical - first film...no CHARGE 5750/5751/5760/5761 Relining (laboratory)...$35.00 * 0230 Intraoral - periapical - each additional film...no CHARGE EXTRACTIONS/ORAL SURGERY 0270 Bitewings - single film...no CHARGE 7110 Single tooth...$ Bitewings - two films... NO CHARGE 7120 Each additional tooth (per visit)...$ Bitewings - four films...no CHARGE 7130 Root removal - exposed roots...$ Panoramic...NO CHARGE 7210 Surgical extraction of erupted tooth...$40.00 PREVENTIVE 7220 Soft tissue impaction...$ /1120 Prophylaxis (routine, once every 6 months)...no CHARGE 7230 Partially bony impaction...$ /1120 Additional prophylaxis...$ Completely bony impaction...$ /1203 Topical application of fluoride 7250 Surgical removal of residual tooth roots...$25.00 (up to 16 years of age)...no CHARGE 7310 Alveoloplasty in conjunction 1351 Sealant - per tooth...$10.00 with extractions - per quadrant...$ Oral hygiene instruction...no CHARGE 7320 Alveoloplasty not in conjunction SPACE MAINTAINERS with extractions - per quadrant...$ Fixed, unilateral...$55.00 * 7510 Incision and drainage (intraoral)...$ Fixed, bilateral...$55.00 * ANESTHESIA 1520 Removable, unilateral...$85.00 * 9215 Local anesthesia... NO CHARGE 1525 Removable, bilateral...$85.00 * 9230 Analgesia (nitrous oxide - per 15 minutes)...$ Recementation of space maintainer...$10.00 ADJUNCTIVE SERVICES RESTORATIVE (Fillings) 9951 Occlusal adjustment - limited...$ Sedative base (under fillings)...no CHARGE 9952 Occlusal adjustment - complete...$ Amalgam (Silver) 2110/2140 One surface...$ /2150 Two surfaces...$ /2160 Three surfaces...$ /2161 Four or more surfaces...$35.00 Resin restoration (Including acid etch, glass ionomer liner) ORTHODONTICS 8070/8080/8090 Children up to 19 years of age Up to 24 months of routine orthodontic treatment for Class I and Class II cases Consultation...NO CHARGE Evaluation...$ Anterior one surface...$35.00 Records/Treatment Planning...$ Anterior two surfaces...$40.00 Orthodontic Treatment...$1, Anterior three surfaces...$ Adults 19 years of age and over 2510 Inlay - metallic - one surface...$85.00 Up to 24 months of routine orthodontic treatment for Class I 2520 Inlay - metallic - two surfaces...$95.00 and Class II cases 2530 Inlay - metallic - three surfaces...$ Consultation...NO CHARGE 2940 Sedative filling...$15.00 Evaluation...$35.00 CROWN & BRIDGE Records/Treatment Planning...$ Prefabricated stainless steel - primary tooth...$50.00 Orthodontic Treatment...$1, /2791/2792/6790/6791/6792 Full cast crown...$ /2751/2752/6750/6751/6752 Porcelain fused to metal crown..$ Retention... Additional 2810 Three quarter cast crown...$ Pontics 6210/6211/6212 Full cast pontic...$ THE ABOVE COPAYMENTS DO NOT INCLUDE THE ADDITIONAL COST OF PRECIOUS AND SEMI-PRECIOUS METAL. 6240/6241/6242 Porcelain fused to metal pontic...$ Core build up...$45.00 All procedures listed may not be performed by the Participating General 2951 Pin Retention - Per Tooth...$12.00 Dentist you select. The copayments shown apply to those CompDent 2952 Cast post and core...$95.00 Participating General Dentists who do perform those services. Therefore, you 2954 Prefabricated post and core...$80.00 are encouraged to discuss availability of the scheduled services with your 2910/2920/6930 Recement inlay/onlay/crown/bridge (per unit)...$15.00 ENDODONTICS Participating General Dentist. Procedures not listed on the schedule of benefits, that are performed by the selected Participating General Dentist will be 3220 Therapeutic pulpotomy...$30.00 charged at that Participating General Dentist s usual and customary fee less Root Canals 25% Anterior...$ Bicuspid...$ SPECIALISTS: Should you need a specialist (i.e., Endodontist, 3330 Molar...$ Orthodontist, Oral Surgeon, Periodontist, Prosthodontist, Pediatric Dentist), 3410 Apicoectomy (anterior only)...$ you may be referred by your Participating General Dentist. Copayment PERIODONTICS (Gum treatment) amounts are applicable when treatment is performed by selected Participating 4210 Gingivectomy/gingivoplasty - per quadrant...$ General Dentist or by Participating Specialists. Benefits for procedures not 4211 Gingivectomy/gingivoplasty - per tooth...$40.00 listed on the schedule of benefits, that are performed by a Participating 4220 Gingival curettage, surgical - per quadrant...$75.00 Specialist are available at the Participating Specialist s usual and customary 4260 Osseous surgery - per quadrant...$ fee less 25% Free soft tissue graft...$ Periodontal scaling and root planing - per quadrant...$45.00 NOTE: When crown and/or bridgework exceeds six consecutive units, the 4355 Full mouth debridement...$38.00 patient may be charged an additional $25.00 per unit Localized delivery of chemotherapeutic agents (2 teeth)... $45.00 * Plus laboratory fees when applicable Periodontal maintenance procedures...$45.00 PROSTHODONTICS Standard complete dentures (includes adjustments within 30 days) 5110 Complete maxillary (upper)...$ Complete mandibular (lower)...$ USSBP P25
2 Limitations and Exclusions 1. No service of any dentist other than a Participating General Dentist or Participating Specialist wil be covered by Company, except out-of-area emergency care as provided in Section VIII, Paragraph C of the Certificate of Benefits. 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. USSBP P25
3 Frequently asked questions Q. What are PRESTIGE plans? With your PRESTIGE Plan, you are not limited to a specific number of visits per year. A. CompBenefits PRESTIGE plans are network-based products that emphasize prevention and cost containment. These plans provide savings off regular dental procedures. Q. How does the plan work? A. Your primary dentist will provide all of your routine dental care. You may be required to pay a co-payment for some services provided by your primary care dentist. The copayments or discounted charges are billed at the time of service, so there are no claim forms to file. You pay your dentist directly, if applicable. Q. How many times a year can I visit my dentist? A. You are encouraged to visit your dentist regularly. With your PRESTIGE Plan, you are not limited to a specific number of visits per year. Q. How do I make appointments? A. Making an appointment is easy. Once you have selected your participating dentist, simply call the dental office on or after the date you receive your certificate of coverage and make your appointment. Your enrollment information will already be at the participating dentist s office or on its way to confirm that you are eligible for treatment. Q. What if I need a specialty dentist? A. When you need treatment from a specialty dentist, you can visit one of the participating specialty dentists from our network, and he or she will reduce normal charges by 25 percent. Q. Is there any maximum coverage limitation? A. No, there are no maximum coverage limitations. GCA0CWJHH 0111
4 Q. How do I pay for services? A. You make your co-payments to the dentist at time of service. Q. What if I go to a non-participating dentist? A. You will not be eligible for benefits from a non-participating dentist. You must seek treatment from the participating dentist you selected. Q. Can I change participating dentists? A. Yes. You can easily change dentists by logging onto Q. Can I go online to find out more about my plan or get assistance? A. Yes. After you enroll, you can visit to register and learn about your plan, to check your benefits, to use our Provider Locator, to change your dentist selection, to send us an and more. Q. How do I order an ID card? A. You can download and print a temporary ID card or order a new ID card at or you can call our Customer Care department at GCA0CWJHH 0111
5 For Assistance :
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7 Fax number or changes to: CHANGE OF STATUS CARD MEMBER NUMBER (Social Security #) LAST NAME FIRST MI EFFECTIVE DATE OF CHANGE GROUP NAME Ivy Tech Community College CHANGE INFORMATION Terminate Please State Reason: Change Name To: Address: Add Delete Dependent(s) Reason: Spouse Child Child Child Last Name First MI Sex Birthdate Mo Day Yr Signature Date
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9 Benefits Enrollment Form Group Name: Ivy Tech Community College Please complete the following information: Social Security No. Last Name First Middle Date of Birth Home Address Home Phone Gender City State ZIP Code Business Phone Facility Number List All Your Eligible Dependents That Are To Be Covered Spouse: First MI Last Facility Number M Sex F Birth Date Child: M F Child: M F Child: M F Child: M F Child: M F Child: M F Effective Date Plan Code Group Number Your Address Agent Code PLEASE CHECK YOUR CHOICE Dental Plan Employee Only Employee + Spouse Employee + Child(ren) 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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Page 1 of 5 0120 0120 0140 0140 0150 0150 0460 0470 0999 9310 9310 9430 9440 0210 0220 0230 0240 0270 0272 0274 0330 1110 1120 1999 1201 1203 1204 1310 1330 1351 9999 1510 1515 1550 2110 2120 2130 2131
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D0999 Office visit during regular hours, general dentist only * $5 Evaluations D0120 Periodic oral examination established patient 0 D0140 Limited oral evaluation problem focused 0 D0145 Oral evaluation
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STRENGTH. STABILITY. SECURITY.
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Improve your smile and overall well-being with. Dental Health Services. Dental Health Services. Difference today!
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Diagnostic No One of (D0210, D0330) per 36 Month(s) Per patient No No Ten of (D0230) per 1 Day(s) Per patient.
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CHOICES Patients Covered dental services
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Where a restoration is provided, no payment will be made for stainless steel crown or prefabricated plastic crown for thirty (30) days.
CHILD DENTAL BENEFITS Effective July 1, 2017 to June 30, 2019 Child dental coverage is provided to dependant children of Alberta Adult Health Benefit (AAHB) and Income Support receipients (Expected to
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