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DINA |
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PLAN FEATURES INCLUDE: BENEFITS
COVERAGE
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Claims
Forms Not Required
Our payment of the benefits by capitation eliminates your need to file claim forms. You deal directly with your selected dentist when you need any of the covered dental services. You must pay all co-payments to your selected dentist as they become due and payable. |
SPECIALISTS
DENTAL SERVICES
Limited benefit -- This plan is contracted with
orthodontists and other specialists who are willing to participate.
Participating specialists may not, however, be available in all parts of
the state, or for all categories of specialist dental services you may
need. A member's initial consultation with a participating specialist is
no charge, after which the participating specialist provides a 20%
discount for services the participating specialist performs. EMERGENCY DENTAL CARE When yournparticipating family dentist is unavailable or when you are away from home, you may seek emergency dental care from any available dentist. The Plan will reimburse up to $50.00 per emergency, limited to $100.00 per policy per year, for emergency dental care. |
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WHO IS ELIGIBLE You, your spouse and eligible dependents less than 21 years old are eligible to be covered under on certificate of insurance. Eligible dependents less than 24 years of age are eligible if attending trade school or college as a full time student. Important Note: All family members covered by one certificate of insurance must use the same participating family dentist. |
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| HOW IT WORKS
To enroll you must complete an enrollment form and mail it to the address below or fax it to the number below. At the time of enrollment you must select a Participating Dentist from the list. This location is now the center for all your dental needs. After you have enrolled and money has been received, you will receive a Cerficate of Benefits, a complete listing of co-payments and an ID card. Your ID card will have the address and telephone number of your participating dentist. To receive all necessary dental care covered by the plan, simply call your selected provider to make an appoitment. |
Bi-Weekly
Payroll Deduction
Individual ............................. $13.00
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WHEN WILL
COVERAGE BE EFFECTIVE All coverage becomes effective on the 1st of the month. If we receive your application and first month's premium before the 10th of the month, your coverage will be effective on the 1st of the following month. Applicants whose information is received after the 10th of the month will be effective one month later. Once covered, you are eligible for all benefits offered under the plan. |
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| SUMMARY OF BENEFITS | |||
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DIAGNOSTIC Periodic oral exam (Limited, once every 6
months)......................... No Charge PREVENTIVE Prophylaxis-(adult/child) two per 12
months................................... No Charge RESTORATIVE Amalgam ENDODONTICS ROOT CANAL PROSTHETICS Crown-resin with predominately base
metal...........................................$275.00 |
PERIODONTICS Gingivectomy or Gingivoplasty - per
quandrant .................................. $145.00 ORAL SURGERY Extraction - single
tooth..............................................................................
$30.00 ADJUNCTIVE GENERAL SERVICES Palliative (emergency) treatment dental
pain-minor procedure.............. $25.00 |
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| Please
Note
This is only a summary of co-payments and benefits. |
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Click here to go to Enrollment Form