ECESD: Dental Benefits Summary

Dental Benefit Summary Basic Option

 BENEFIT MAXIMUMS

Calendar Year Maximum
Orthodontia Lifetime Maximum
TMJ Lifetime Maximum

 

$1000
$1000
$500

Benefits for each Covered Person will not exceed the maximums shown above.
Orthodontia benefits do not apply to the Calendar Year Maximum.  The Orthodontia Maximum applies to all periods a child is covered under the Plan.
Benefits for Eligible Dental Expenses that are related to treatment of TMJ (i.e., disorders of the temporomandibular joint) are subject to both the Calendar Year Maximum and the TMJ Lifetime Maximum.
 ANNUAL DEDUCTIBLES

Individual Deductible
Family Maximum Deductible

  

$25
$75

Network and Non-network providers

The Plan Sponsor has contracted with “Networks” of dental providers. Network providers have agreed to provide dental services at negotiated rates.  Lists or directories of the Network providers will be given to Plan participants without charge.

When obtaining dental care services in the United States, a Covered Person has a choice of using a provider who is participating in the First Dental Health Network (FDH) or any other Covered Provider of his choice (a Non-Network provider).  For in-Mexico services, a First Dental Health (AMEXUS) Network provider or a participating dental laboratory must be used.

When a Covered Person uses a Network provider his out-of-pocket costs may be reduced because he will not be billed for expenses in excess of “Usual, Customary and Reasonable.”  The Schedule of Dental Benefits (below) may also include other benefit incentives to encourage Covered Persons to use Network providers whenever possible.

Schedule of Dental Benefits

ELIGIBLE DENTAL
EXPENSES

FDH Network
(Stateside)

Non-Network
(Stateside)

AMEXUS Network
(Mexico)

Diagnostic &
Preventive Services

100%†

80%†

100%†

Diagnostic & Preventive Services include the following, some of which are limited by age or frequency as shown below.  See the Eligible Dental Expenses section for further detail:

· Biopsy / pathology
· Consultation
· Diagnostic casts
· Exams and cleanings, limited to 2 exams/cleanings per Calendar Year
· Fluoride, limited to 2 applications per Calendar Year
· Palliatives
· Sealants, limited to children under age 14
· Space maintainers
· Study models
· X-rays.  Full mouth series or panoramic X-ray, limited to once per 5-year period.  Routine bitewings, limited to 2 sets per Calendar Year for children under age 18 and 1 set per Calendar Year for persons age 18 and over.

Basic Services

70% – 100%††

60%

70% – 100%††

Basic Services include the following.  See the Eligible Dental Expenses section for further detail:

· Anesthesia
· Casts
· Crowns
· Endodontia
· Fillings
· Injections
· Oral surgery / extractions
· Periodontal
· Visits, non-routine

ELIGIBLE DENTAL
EXPENSES

FDH Network
(Stateside)

Non-Network
(Stateside)

AMEXUS Network
(Mexico)

 Major Services

50%

40%

50%

Major Services include the following.  See the Eligible Dental Expenses section for further detail:

· Implants
· Prosthodontics (dentures & bridges)
· Repairs, recementings, relines, etc.

Orthodontia

50% to
$1000
Lifetime

50% to
$1000
Lifetime

50% to
$1000
Lifetime

 Orthodontia benefits are limited to a maximum 24-month treatment program.

† Annual Deductible does not apply.
†† The 70% benefit will apply to benefits provided during a person’s first Calendar Year (or partial year) of coverage.  The percentage increases by 10% each consecutive year a dentist is visited to a maximum benefit of 100%.  If a dentist is not visited during a year, the percentage remains at the percentage level reached in the prior year.  If coverage is terminated and later resumed, benefits restart at the 70% benefit level.

Dental Benefit Summary Buy-Up Option

BENEFIT MAXIMUMS

Calendar Year Maximum
Orthodontia Lifetime Maximum
TMJ Lifetime Maximum

$1500
$1500
$500
Benefits for each Covered Person will not exceed the maximums shown above.
Orthodontia benefits do not apply to the Calendar Year Maximum.  The Orthodontia Maximum applies to all periods a child is covered under the Plan.
Benefits for Eligible Dental Expenses that are related to treatment of TMJ (i.e., disorders of the temporomandibular joint) are subject to both the Calendar Year Maximum and the TMJ Lifetime Maximum.
ANNUAL DEDUCTIBLES

Individual Deductible
Family Maximum Deductible

  

$25
$75

Network and Non-network providers

The Plan Sponsor has contracted with “Networks” of dental providers. Network providers have agreed to provide dental services at negotiated rates.  Lists or directories of the Network providers will be given to Plan participants without charge.

When obtaining dental care services in the United States, a Covered Person has a choice of using a provider who is participating in the First Dental Health Network (FDH) or any other Covered Provider of his choice (a Non-Network provider).  For in-Mexico services, a First Dental Health (AMEXUS) Network provider or a participating dental laboratory must be used.

When a Covered Person uses a Network provider his out-of-pocket costs may be reduced because he will not be billed for expenses in excess of “Usual, Customary and Reasonable.”  The Schedule of Dental Benefits (below) may also include other benefit incentives to encourage Covered Persons to use Network providers whenever possible.

Schedule of Dental Benefits

ELIGIBLE DENTAL
EXPENSES

FDH
Network

(Stateside)

Non-Network
(Stateside)

AMEXUS Network
(Mexico)

Diagnostic &
Preventive Services

100%†

80%†

100%†

Diagnostic & Preventive Services include the following, some of which are limited by age or frequency as shown below.  See the Eligible Dental Expenses section for further detail:

· Biopsy / pathology
· Consultation
· Diagnostic casts
· Exams and cleanings, limited to 2 exams/cleanings per Calendar Year
· Fluoride, limited to 2 applications per Calendar Year
· Palliatives
· Sealants, limited to children under age 14
· Space maintainers
· Study models
· X-rays.  Full mouth series or panoramic X-ray, limited to once per 5-year period.  Routine bitewings, limited to 2 sets per Calendar Year for children under age 18 and 1 set per Calendar Year for persons age 18 and over.

 Basic Services

70% – 100%††

60%

70% – 100%††

Basic Services include the following.  See the Eligible Dental Expenses section for further detail:

· Anesthesia
· Crowns
· Endodontia
· Fillings
· Injections
· Oral surgery / extractions
· Periodontal
· Visits, non-routine

ELIGIBLE DENTAL
EXPENSES

FDH
Network

(Stateside)

Non-Network
(Stateside)

AMEXUS Network
(Mexico)

Major Services

50%

40%

50%

Major Services include the following.  See the Eligible Dental Expenses section for further detail:
· Inlays, Onlays & Cast Resoration
· Implants
· Prosthodontics (dentures & bridges)
· Repairs, recementings, relines, etc.
Orthodontia

50% to
$1500
Lifetime

50% to
$1500
Lifetime

50% to
$1500
Lifetime

 Orthodontia benefits are limited to a maximum 24-month treatment program.

†Annual Deductible does not apply.
†† The 70% benefit will apply to benefits provided during a person’s first Calendar Year (or partial year) of coverage.  The percentage increases by 10% each consecutive year a dentist is visited to a maximum benefit of 100%.  If a dentist is not visited during a year, the percentage remains at the percentage level reached in the prior year.  If coverage is terminated and later resumed, benefits restart at the 70% benefit level.

Forms

All forms necessary for enrolling, making changes, or filing a claim are available at your fingertips:

P.O. Box 5809
Fresno, CA 93755

(866) 777-1320 Phone

(559) 475-5780 Fax

 

Contact Form on ASI Schools Website

13 + 3 =