Your WellAway Broker: J+C Budmiger GmbH Eta-Glob Help-System CH-3900 Brig / Switzerland Dental Benefits Rider Basic & Major Subject to a USD $ 50 deductible per policy year All benefits In Aggregate USD $ 3,500 Preventive Dental Services: - Examinations two per year - Prophylaxis (Cleanings)- twice per year Basic Dental Treatment: 100% No deductible applies Tel. +41 (0)27 946 60 24 www.eta-glob.ch - Emergency care for pain relief - Amalgam filings - Composite filings (white fillings) - Sedative fillings 70% ( Nine (9) month waiting Period Applies) Major Dental Treatment - Crowns - Inlays and Onlays - Bridgework - Impacted Wisdom Teeth removal 50% ( Nine (9) month waiting Period Applies) Orthodontic Treatment Covered for children under the age of sixteen(16) years 50% Up to $1500 Lifetime $100 Lifetime separate deductible applies (Twelve(12) month waiting Period Applies) Preventive Dental Services: Benefits for Preventive Services are listed below and are payable at 100% of usual reasonable and customary fees. Services under this category is not subject to waiting periods nor Deductible. - Examinations ( Two Per Policy Year) - Prophylaxis (Cleanings)- (Three Per Policy year) - Bitewing x-rays- (Once Per Policy Year) - Periapical x-rays - Full-mouth, panorex x-rays- (One Every three(3) Years) - Fluoride treatments (children under the age of 16)- Two Per Policy Year) - Space Maintainers - Permanent Molars Sealants ( Children under the age of 16) 1
Basic Dental Treatment Services: Benefits for Basic Dental Treatment Services listed below and are payable at 70% of usual reasonable and customary fees subject to a nine month waiting period and a one- time policy year deductible of $50 USD Per Policy Year Per Insured. - Emergency care for pain relief - Amalgam filings - Composite filings (white fillings) - Sedative fillings - Routine Tooth Extractions - Root Canal Therapy - Periodontal Scaling & Root Planing - Recementing Dental Crowns - Stainless Steel (pre-fabricated) Crowns Major Dental Treatment Services: Benefits for Basic Dental Treatment Services listed below and are payable at 50% of usual reasonable and customary fees subject to a nine month waiting period and a one-time policy year deductible of $50 USD Per Policy Year Per Insured. - Crowns - Inlays and Onlays - Bridgework - Impacted Wisdom Teeth removal - Complex oral Surgery Procedures - Removable Partial Dentures - Denture Relines and Rebases - Denture Repairs Orthodontic Treatment: Benefits are payable after a twelve (12) month waiting period. We will require the following information with the first claim: - Treatment type - Date braces were or will be put on teeth - X-rays - Total treatment cost - Estimated number of treatment months - American Dental Association treatment code HOW ORTHODONTIC BENEFITS ARE PAID When WellAway receives a claim for orthodontic services, eligibility is verified and orthodontic claims history is checked for application of benefit to maximum payments. WellAway s payment amount is then calculated based on the payment percentage of WellAway s allowance and the lifetime maximum for orthodontics. 2
Scenario 1 New Orthodontia Treatment The orthodontist submits to WellAway a treatment plan that includes such details as cost and duration of treatment. WellAway calculates its total liability. Assuming that the total liability is at least $1,500, WellAway s will pay $750 upon receipt of the initial claim. WellAway will make the second payment of $750 12 months after the bands are placed, provided the patient is still eligible for second year of treatment scheduled longer than 12 months. For treatment scheduled for less than 12 months, WellAway will pay full liability up front. Scenario 2 WellAway s coverage becomes effective after the start of an orthodontic treatment plan that was covered by a prior dental plan: The orthodontist should submit a claim with the treatment plan, an explanation of the status of the treatment plan, and evidence of the amount paid to date by the subscriber and/or the prior insurance carrier(s). WellAway will review the treatment plan and determine its liability in the absence of other coverage. In the event there is other coverage, WellAway will then coordinate benefits by reducing its payment by the amount covered by any other carriers. We will not pay more than Our contracted maximum lifetime amount for orthodontic services minus the previous carrier payments. Example: The orthodontic treatment plan costs $2500 for 24 months. Another carrier paid $1250. WellAway s liability in the absence of other insurance would be $1,500, the contracted maximum lifetime amount for orthodontic services in this case. Here, WellAway s Dental liability is reduced by the $1250 paid by another carrier, which makes WellAway s Dental liability $1250. Scenario 3 WellAway coverage becomes effective after the start of an orthodontic treatment plan that was NOT covered by a prior dental plan The orthodontist should submit a claim with the treatment plan, an explanation of the status of the treatment plan, and evidence of the amount paid to date. WellAway calculates the original liability on the claim, and then divides that amount by the total number of months left to complete treatment in order to calculate a monthly payment. That benefit is then multiplied by the number of remaining months in the treatment plan. This amount represents WellAway s Dental total liability. Example: The orthodontic treatment plan costs $2500 for 24 months. The patient paid $1,250 out of pocket toward the first 12 months of treatment. However, this is not a factor in the calculation of WellAway s Dental liability because coverage by WellAway did not begin until after the first 12 months of treatment. WellAway s Dental lifetime maximum benefit for orthodontic services is $1,500. The monthly payment is calculated as $65.50 per month ($1,500 divided by 24 months = $62.50). There are 12 remaining months of treatment. The monthly benefit multiplied by the number of remaining months is $750. ($60.50 X 12 = $750). This amount represents WellAway s Dental total liability. Exclusions: 1. Services prior to effective date of the policy, during waiting period or after termination date. 3
2. Unlisted services; Services not specifically listed in the benefit schedule. 3. Excess Amounts: any amount in excess of the maximum amounts stated in the schedule of benefits. 4. Night guards. 5. Any amount over usual reasonable and customary for the service. 6. Fluoride applications for patients over sixteen (16) years of age. Fluoride applications exceeding two visits per year. 7. Experimental or Investigational Procedures; Services we consider being experimental or investigative. 8. Replacement of teeth missing prior to the effective date of coverage. 9. Services for periodontics, fixed or removable prosthodontics within the first 12 months of the insured person s effective date. 10. Replacement of an existing prosthesis, which has been lost or stolen. Replacement of a fixed or removable prosthesis if such replacement occurs within five years of the original placement, unless the denture is a stay plate used during the healing period for recently extracted anterior teeth. 11. Services for which you are not legally obligated to pay: services for which no charge would have been made to you in the absence of Insurance. 12. Services from relatives: Professional services received from a person who lives in the insured person s home or who is related to the insured person by blood, marriage or adoption. 13. Cosmetic Dentistry: Any services performed for cosmetic purposes are not covered under this plan including but not limited to: dental implants, teeth bleaching, veneers 14. Implants (materials implanted into or on bone or soft tissue), or the removal of implants are not benefits under the policy. 15. Charges for treatment by other than a licensed dentist or physician, except charges for dental prophylaxis performed by a licensed dental hygienist, the supervision and direction of a dentist. 16. Orthodontic services, braces, appliances and all related services for adults over the stated age limit. 17. Diagnosis or treatment of the joint of the jaw and/ or occlusion (the way upper and lower teeth meet) services, supplies or appliances provided in connection with: (a) any treatment to alter, correct, fix, improve, remove, replace, reposition, restore or otherwise treat the joint of the jaw (temporomandibular joint) or associated musculature, nerves and other tissues for any reason or by any means; or (b) any treatment, including crowns, caps and/or bridges to change the way the upper and lower teeth meet (occlusion); or (c) treatment to change vertical dimension (the space between the upper and lower jaw) for any reason or by any means including the restoration of vertical dimension because teeth have worn down. 18. Procedures requiring appliances or restorations (other than those for replacement of structure loss from cavities) that are necessary to alter, restore or maintain occlusions. These include but are not limited to: (a) changing the vertical dimension; (b) replacing or stabilizing lost tooth structure by attrition, abrasion, or erosion; (c) realignment of teeth; (d) gnathological recording; (e) occlusal equilibration; (f) periodontal splinting. 19. Adjustment, repairs or relines to prosthesis except following 6 months from initial placement and if the prosthesis was paid for under this plan. 20. Fixed bridges, removable cast partials and/or cast crown with or without veneers for patients under sixteen years of age. 21. Replacement of crowns and cast restorations including porcelain crowns, if such replacement occurs within five years of the original placement. 22. Prescribed drugs, pre-medication or analgesia. 23. Oral hygiene instructions. 24. Malignancies and neoplasms: Services for treatment of malignancies and neoplasms are not covered services. 4
25. All hospital costs and any additional fees charged by the dentist for hospital treatment. 5