LIMITATIONS AND EXCLUSION:

ARBITRATION: The Plan uses binding arbitration to resolve any and all disputes between the Plan and group or member, including, but not limited to, allegations against Plan of medical malpractice (that is an to whether any dental services rendered under the Plan were unnecessary or unauthorized or were improperly, negligently or incompetently rendered) and other disputes relating to the delivery of services under the Plan.

Plan, group and member each understand and expressly agree that by entering into the Plan services group subscriber agreement or enrolling in Plan and agreeing to be bound by the Plan subscriber agreement. Plan, group and member are each voluntarily giving up their constitutional right to have all such disputes decided in a court of law before a jury and instead are accepting the is of binding arbitration. Group and member further contracting provider including but not limited to claims against a Plan contracting provider for medical malpractice are not governed by the Plan subscriber agreement.

However Plan, group and member each expressly agree that the existence of any disputes between group or member and a Plan contracting provider, including but not limited to claims by groups or member against a Plan contracting provider for medical malpractice shall in no way affect the obligation to submit to binding arbitration all disputes between group or member and Plan.

LIMITATIONS: Dentures or partials once every five years and then only when dentures cannot be made serviceable; cleanings once every six months; redlines not more than twice per year; full mouth x-rays once every two years; all family members must be assigned to the same dental office; orthodontic treatment must be provided by a member of the Plan Orthodontic Panel.

EXCLUSIONS: Oral surgery requiring the setting of fractures or dislocations; treatment of malignancies, cysts or neoplasms; dispensing of drugs; teeth extracted for orthodontic purposes; cosmetic dentistry; treatment of temporomandibular joint syndrome (tmj); treatment by a specialist.

DISCLOSURE: An application is a request for coverage which if approved by the Plan would then become the enrollment form and would be used to issue an identification card and a Disclosure Form. Upon acceptance of the application by the Plan, your benefits will become effective on the first of the next month. Detailed limitations and exclusions, coverage benefits, co-payments, as well as other services offered, are given in full in the Disclosure Form provided when coverage becomes effective. The Insurance Company always reserves the right to make the final determination with respect to all aspects of this Dental Program.

If the SUBSCRIBER has a newborn infant, this Contract and Evidence of Coverage shall cover the newborn infant immediately from the moment of birth for 31 days. If the SUBSCRIBER adopts a child who is a minor, this Contract and Evidence of Coverage shall cover the adopted child immediately from the date on which the SUBSCRIBER has a right to control health care for the adopted child for 31 days. Coverage for a newborn infant or adopted child will continue beyond 31 days only if the SUBSCRIBER applies for membership for the child using PLAN forms during that 31-day period and the other eligibility requirements set forth above have been met. F. PLAN will not end the membership of a DEPENDENT who is a child upon reaching age 19 if he or she is incapable of self-sustaining employment because of mental retardation or physical handicap. PLAN may require proof of his or her incapacity and dependency. The SUBSCRIBER must provide that proof within 31 days of request by PLAN. If the child is age 21 or older, PLAN will not request this information more than once each year. G. PLAN will not end the membership of DEPENDENT who is a child upon reaching age 19 if he or she is a full-time student at an accredited secondary school, trade school, college, or university. PLAN may require proof of his or her fulltime status. “Full-time status” means the child is taking courses for at least 12 credit hours in each academic period. The SUBSCRIBER must provide that proof within 31 days of request by PLAN. A full-time student may continue as a MEMBER even if he or she lives outside the SERVICE AREA. PLAN will not continue membership for a full-time student after age 23.

Restorative Amalgam Restorations (Including Polishing)
2110 Amalgam – One Surface – Primary $6
2120 Amalgam – Two Surfaces – Primary $11
2130 Amalgam – Three Surfaces – Primary $13
2131 Amalgam – Four or More Surfaces – Primary $19
2140 Amalgam-One Surface – Permanent $8
2150 Amalgam-Two Surfaces – Permanent $13
2160 Amalgam-Three Surfaces – Permanent $21
2161 Amalgam-Four or More Surfaces – Permanent $24
2332 Resin Restoration – Three Surfaces – Anterior $28
2335 Resin Restoration – Four or More Surfaces – Anterior $34

These were the costs I found that you would pay. Is this correct?

Thanks, SW.