voluntary plus plan #5 pcn ppo non-network · d0220 intraoral-periapical-first film 15.00 d0230...
TRANSCRIPT
Group Name: Manco Abbott, Inc.
Benefit Plan Name: Voluntary Plus Plan #5
Schedule of Benefits
N/A
N/A
N/A
N/A
No
Yes
3 per Family
Yes
3 per Family 3 per Family
No No
N/A
N/A
No
N/A
N/A
PCN PPO NON-NETWORK
Class I / Preventive
Class II / Basic
Class III / Major
Benefit Year
Deductible
Waived for Preventive?
Family Deductible
Benefit Year Max
Class IV / Orthodontia
Ortho Coverage
Ortho Lifetime Max
TMJ Rider
TMJ Lifetime Max
Wait Period for Major -Existing Employees
-New Hire
Wait Period for Ortho -Existing Employees
-New Hire
100% 100% 100%**
90% 80% 80%**
60% 50% 50%**
$25 $50 $50
$1,000 $1,000 $1,000
N/A
N/A
No No
N/A N/A
***
***
***
***
***
***
12 Months 12 Months 12 Months
12 Months 12 Months 12 Months
N/A
N/A
**** ****
Yes
N/A
** Allowed Charge Limited to Covered Fee Schedule
*** Waived with Prior Coverage
**** Premier Access does not guarantee all services can be rendered by a contracted PCN or PPO provider. You may be
subject to a deductible and co insurance for an out of network Specialist.
Page 1 of 2
Group Name: Manco Abbott, Inc.
Benefit Plan Name: Voluntary Plus Plan #5
Schedule of Benefits
Class I / Preventive
Class II / Basic
Class III / Major
Oral Exams, Full Mouth
X-Rays/Pano, Bitewings, Other
X-Rays, Prophylaxis, Fluoride
Oral Exams, Full Mouth
X-Rays/Pano, Bitewings, Other
X-Rays, Prophylaxis, Fluoride
Oral Exams, Full Mouth
X-Rays/Pano, Bitewings, Other
X-Rays, Prophylaxis, Fluoride
Sealants, Space Maintainers,
Restorations, Emergency(Palliative),
Oral Surgery
Sealants, Space Maintainers,
Restorations,
Emergency(Palliative), Oral
Surgery
Sealants, Space Maintainers,
Restorations,
Emergency(Palliative), Oral
Surgery
Inlays, Crowns, Bridges, Dentures,
Endodontics, Periodontal
Maintenance, Root Planing,
Periodontal Surgery
Inlays, Crowns, Bridges, Dentures,
Endodontics, Periodontal
Maintenance, Root Planing,
Periodontal Surgery
Inlays, Crowns, Bridges, Dentures,
Endodontics, Periodontal
Maintenance, Root Planing,
Periodontal Surgery
NON-NETWORK PPOPCN
The Dental Program offered is administrated by Premier
Access Insurance Company, a national carrier and widely
accepted dental plan.
What is important to know about your dental plan is that you
may see any dentist. Although, there are PCN (Premier
Choice Network) and PPO provider lists available, and the
benefits are enhanced if you elect to use either network, you
may elect to see the dentist of your choice without penalty.
Using the PCN or PPO providers, you maximize your benefits
and reduce your out-of-pocket costs.
The PPO dentists offer discounted care (about 30%) and the
plan normally pays a higher level of benefit when using an
in-network provider. Additionally, the PCN/PPO dentist
cannot "balance bill" you for amounts greater than the
contracted rate.
How It Works
Out-of-State Network and Claims
The Premier Access Dental network is available to eligible
members outside the State of California, with nearly
80,000 dentists to choose from. A complete provider
listing is available on the internet at: www.premierlife.com.
It is important that you confirm with your dentist at the time
of treatment that they are participating in the Premier
Access network. For a dentist near you call 888.715.0760.
Please check your Certificate of Insurance for a description
of coverage, limitations and exclusions under the plan.
Some services require prior authorization.
How to Reach Us
Premier Access Claim Dept.
P.O. Box 659010
Sacramento, CA 95865-9010
Member Services Line
888.715.0760
On the Web
www.premierlife.com
Page 2 of 2
PROCEDURE
CODEPROCEDURE DESCRIPTION
MAX
ALLOWANCE
D0120 Periodic Oral Evaluation 15.00
D0140 Limited Oral Evaluation 21.00
D0145 Oral evaluation for a patient under three years of age and counseling with primary caregiver 15.00
D0150 Comprehensive Oral Eval. 21.00
D0170 Re-Evaluation, Limited Problem Focused 15.00
D0180 Comprehensive Perio Exam 21.00
D0190 Screening of a patient 15.00
D0191 Assessment of a patient 15.00
D0210 Intraoral-Compl Ser Incl Bitewings 57.00
D0220 Intraoral-Periapical-First Film 15.00
D0230 Intraoral-Periapical-Each Add. Film 5.00
D0240 Intraoral-Occlusal Film 14.00
D0270 Bitewings-Single Film 15.00
D0272 Bitewings-Two Films 23.00
D0273 Bitewings-Three Films 29.00
D0274 Bitewings-Four Films 31.00
D0277 Vertical Bitewings 7-8 Films 48.00
D0330 Panoramic Film 48.00
D0340 Cephalometric Film 38.00
D0341 Cephalometric Film, additional 38.00
D0350 Ortho x-ray Survey 25.52
D0371 Sialoendoscopy capture and interpretation 640.00
D0415 Bacteriologic Studies for Determination 13.00
D0470 Diagnostic Casts 47.00
D1110 Prophylaxis-Adult 40.00
D1120 Prophylaxis-Child 30.00
D1203 Topical application of fluoride (prophylaxis not included) - child 10.00
D1204 Topical application of fluoride (prophylaxis not included) - adult 5.00
D1205 Top Appl Fluor Incl Prophy-Adult 40.00
D1206 Topical fluoride varnish; therapeutic application for moderate to high caries risk patients 18.00
D1208 Topical Application Of Fluoride 10.00
D1351 Sealant-Per Tooth 25.00
D1510 Space Maintainer-Fixed Unilateral 145.00
D1511 SS CROWN TYPE, FIXED 178.00
D1515 Space Maintainer-Fixed Bilateral 210.00
D1520 Space Maintainer-Remove Unilateral 180.00
D1525 Space Maintainer-Remove Bilateral 230.00
D1550 Recementation Of Space Maintainer 31.00
D1555 Removal of fixed space maintainer 30.00
D2110 Amalgam-One Surface Primary 41.00
D2120 Amalgam-Two Surfaces Primary 52.00
D2130 Amalgam-Three Surfaces Primary 61.00
D2131 Amalgam -4 Or More Surfaces, Primary 73.00
D2140 Amalgam-One Surface 51.00
D2150 Amalgam-Two Surfaces 60.00
D2160 Amalgam-Three Surfaces 75.00
D2161 Amalgam-Four Or More Surf 84.00
D2330 Resin-One Surf. Anterior 65.00
M1
EXHIBIT A - FEE SCHEDULE
Page 1 of 6 M1-CDT14
M1
EXHIBIT A - FEE SCHEDULE
D2331 Resin-Two Surf. Anterior 70.00
D2332 Resin-Three Surf. Anterior 75.00
D2335 Resin> 3 Surf. Or Inv Incisal Angle Anterior 94.00
D2385 Resin -1 Surf. Posterior Perm. 80.00
D2391 Resin-Based Composite - 1 Surface, Posterior 80.00
D2392 Resin-Based Composite - 2 Surface, Posterior 100.00
D2393 Resin-Based Composite - 3 Surface, Posterior 120.00
D2394 Resin-Based Composite - 4+ Surface, Posterior 155.00
D2510 Inlay-Metallic-One Surf. 275.00
D2520 Inlay-Metallic-Two Surfaces 335.00
D2530 Inlay-Metallic-3 Or More Surf. 370.00
D2540 Onlay-Metallic Per Tooth In Add.To Inlay 100.00
D2542 Onlay - metallic two surfaces 388.00
D2543 Onlay-Metallic -3 Surfaces 406.00
D2544 Onlay - metallic three or more surfaces 422.00
D2610 Inlay-Porc/Ceramic -One Surf. 356.00
D2620 Inlay-Porc/Ceramic -Two Surf. 376.00
D2630 Inlay-Porc/Ceramic -3 Or More Surf. 400.00
D2642 Onlay- Porc/ Ceramic 2 surface 388.00
D2643 Onlay -Porcelain/ Cerm three surface 406.00
D2644 Onlay Porcelain 4+ surface 422.00
D2710 Crown-Resin-Laboratory 175.00
D2740 Crown-Porc/Ceramic Substrate 475.00
D2750 Crown-Porc.Fused To Hi Noble Metal 500.00
D2751 Crown-Porc.Fused To Predom Base Metal 500.00
D2752 Crown-Porc.Fused To Noble Metal 500.00
D2780 3/4 cast high noble metal 432.00
D2781 3/4 cast predominantly base metal 407.00
D2782 3/4 cast noble metal 420.00
D2783 3/4 Porcelain / Ceramic 445.00
D2790 Crown-Full Cast High Noble Metal 500.00
D2791 Crown-Full Cast Predom Base Metal 500.00
D2792 Crown-Full Cast Noble Metal 500.00
D2910 Recement Inlay 30.00
D2920 Recement Crown 30.00
D2921 reattachment of tooth fragment, incisal edge or cusp 30.00
D2929 Prefabricated Porcelain/Ceramic Crown - Primary Tooth 90.00
D2930 Prefab Stainless Steel Crown-Primary Tooth 90.00
D2931 Prefab Stainless Steel Crown-Perm Tooth 100.00
D2932 Prefab Resin Crown 95.00
D2933 Prefab Stainless Steel Crown w/ Resin WDW 130.00
D2940 Sedative Fillings 35.00
D2941 interim therapeutic restoration - primary dentition 25.00
D2950 Build Up - Including Any Pins 85.00
D2951 Pin Retention Per Tooth In Add.To Rest. 25.00
D2952 Cast Post and Core In Add To Crown 133.00
D2954 Prefab Post and Core In Add To Crown 105.00
D2960 Labial Veneer (Laminate) - Chairside 160.00
D2961 Labial Veneer (Resin Laminate) - Lab. 260.00
D2962 Labial Veneer (Porc. Laminate) - Lab. 285.00
Page 2 of 6 M1-CDT14
M1
EXHIBIT A - FEE SCHEDULE
D2980 Crown Repair -by Report 84.00
D2981 Inlay Repair Necessitated By Restorative Material Failure 120.00
D2982 Onlay Repair Necessitated By Restorative Material Failure 84.00
D2983 Veneer Repair Necessitated By Restorative Material Failure 84.00
D2990 Resin infiltration of incipient smooth surface lesions 40.00
D3110 Pulp Cap - Direct Exclusion Final Rest. 28.00
D3120 Pulp Cap - Indirect Exclusion Final Rest. 35.00
D3220 Therapeutic Pulp. Exclusion Final Rest. 55.00
D3230 PULPAL THERAPY-ANTERIOR, PRIM 70.00
D3240 PULPAL THERAPY-POSTERIOR, PRIM 75.00
D3310 RC Therapeutic Anterior Exclus. Final Rest. 250.00
D3320 RC Therapeutic-Bicusp. Exclus. Final Rest. 310.00
D3330 RC Therapeutic-Molar Exclus. Final Rest. 400.00
D3340 RC Ther-Molar 4 canal 400.00
D3346 RETREAT OF PREVIOUS ROOT CANAL THERAPY, ANTE 338.00
D3347 RETREATMENT OF PREVIOUS ROOT CANAL THERAPY-BICUSPI 403.00
D3348 RETREATMENT OF PREVIOUS ROOT CANAL THERAPY-M 484.00
D3351 APEXIFICATION/RECALCIFICATION-INITIAL VISIT 143.00
D3352 APEXIFICATION/RECALIFICATION, INTERIM 62.00
D3353 APEXIFICATION/RECALCIFICATION-FINAL VISIT 210.00
D3410 Apicoectomy/Periradicular Surg.-Ant. 275.00
D3421 Apicoectomy/Periradicular Surg- Bicus 1st Root 356.00
D3425 Apicoectomy/Periradicular Surg.-Molar 1st Root 375.00
D3426 Apico/Perirad Surg-Ea Add Root 115.00
D3430 Retrograde Filling-per Root 25.00
D3450 Root Amputation -per Root 170.00
D3920 Hemisect w/Root Removal-w/out RCT 140.00
D4210 Gingivectomy/Gingivolplasty -per Quad 180.00
D4211 Gingivectomy/Gingivolplasty -per T 60.00
D4212 gingivectomy or gingivoplasty to allow access for restorative procedure, per tooth 30.00
D4240 Gingival Flap include. Root Plan-per Quad 190.00
D4241 Gingival Flap, 1-3 teeth per quad 105.00
D4249 Crown Length.-Hard Tissue 200.00
D4250 Muco Gingival Surg.-per Quad. 175.00
D4260 Oss Surg. & Flap Ent/ Clos-per Quad. 320.00
D4261 Oss Surg, one to three teeth per quad 171.00
D4263 BONE REPLACE GRAFT 1ST SITE/QUADRANT. 99.00
D4264 Bone Replacement Graft- each add site in quad 49.00
D4266 GUIDED TISSUE REGENERATION-RESORBABLE BARRIE 115.00
D4267 Guide Tissue Regen-Nonresorb Barrier 154.00
D4268 Guide Tissue Regen-Include.Surg.& Re-Entry 199.00
D4270 Pedicle Soft Tissue Graft Procedure 260.00
D4271 Free Soft Tissue Graft & Donor Site 200.00
D4273 Subepithelial Tiss Graft Proc.with Don. 116.00
D4277 Free Soft Tissue Graft Procedure (Including Donor Site Surgery), First Tooth Or Edentulous Tooth Position In Graft 100.00
D4278 Free Soft Tissue Graft Procedure (Including Donor Site Surgery), Each Additional Contiguous Tooth Or Edentulous Tooth Position In Same Graft Site50.00
D4321 Provisional Splinting - Extracoronal 125.00
D4341 Periodontal Root Planing -per Quad 75.00
D4342 Periodontal Scale 1-3 41.00
D4355 FULL MOUTH DEBRIDEMENT TO ENABLE COMPREHENSI 67.00
Page 3 of 6 M1-CDT14
M1
EXHIBIT A - FEE SCHEDULE
D4910 Perio. Maint. Procs. after Active Therapy 60.00
D4930 Emergency Treatment / Periodontal 35.00
D5110 Compl. Denture -Upper 650.00
D5120 Compl. Denture -Lower 650.00
D5130 Immediate Denture -Upper 650.00
D5140 Immediate Denture Lower 650.00
D5211 U Par-Resin BS w/Conv.Clsps-Rsts & Th 425.00
D5212 L Par-Resin BS w/Conv.Clsps-Rsts & Th 425.00
D5213 U Par Cst Mtl Resin BS w/Conv Clsps 750.00
D5214 L Par Cst Mtl Resin BS w/Conv Clsps 750.00
D5225 Maxillary Partial Denture- flexible base 750.00
D5226 Mandibular Partial Denture- flexible base 750.00
D5281 REMOVABLE UNILATERAL PARTIAL DENTURE 372.00
D5410 Adjust Compl. Denture - Upper 30.00
D5411 Adjust Compl. Denture - Lower 30.00
D5421 Adjust Partial Denture- Upper 30.00
D5422 Adjust Partial Denture - Lower 30.00
D5510 Repair Broken Compl.Denture Base 60.00
D5520 Replace Missing/Broken T-Compl. Dent.Ea.T. 50.00
D5610 Repair Resin Denture Base 50.00
D5620 Repair Cast Framework 50.00
D5630 Repair or Replace Broken Clasp 50.00
D5640 Replace Broken Teeth-per Tooth 50.00
D5650 Add Tooth to Existing Partial Denture 65.00
D5660 Add Clasp to Existing Partial Denture 80.00
D5710 Rebase Compl. Upper Denture 250.00
D5711 Rebase Compl. Lower Denture 250.00
D5720 Rebase Upper Partial Denture 250.00
D5721 Rebase Lower Partial Denture 250.00
D5730 Reline Compl. Upper Denture - Chairside 110.00
D5731 Reline Compl. Lower Denture - Chairside 110.00
D5740 Reline Upper Partial Denture - Chairside 110.00
D5741 Reline Lower Part. Denture - Chairside 110.00
D5750 Reline Compl. Upper Denture-Lab. 175.00
D5751 Reline Compl. Lower Denture-Lab. 175.00
D5760 Reline Upper Partial Denture-Lab. 175.00
D5761 Reline Lower Partial Denture-Lab. 175.00
D5820 Interim Partial Denture ( Upper) 185.00
D5821 Interim Partial Denture (Lower) 185.00
D5850 Tissue Conditioning Maxillary 50.00
D5851 Tissue Conditioning Mandibular 50.00
D6010 Surgical placement of Implant body: endosteal implant 1144.00
D6013 surgical placement of mini implant 744.00
D6020 Abutment placement or substitution: endosteal implant 140.00
D6040 Endosteal Implant 955.00
D6050 Surgical Placement: transosteal implant 869.00
D6055 Dental Implant supported connecting bar 120.00
D6056 Prefabricated abutment - includes placement 260.00
D6066 Implant Sup Porcelain Crown 632.00
D6080 Implant maintenance procedures , including removal of prosthesis , cleansing of prosthesis and ab 48.00
Page 4 of 6 M1-CDT14
M1
EXHIBIT A - FEE SCHEDULE
D6092 Recement implant/abutment supported crown 30.00
D6093 Recement implant/abutment supported fixed partial denture 30.00
D6210 Pontic Cast High Noble Metal 410.00
D6211 Pontic Cast Predom Base Metal 410.00
D6212 Pontic Cast Noble Metal 410.00
D6240 Pontic Porc Fused to Hi Noble Metal 410.00
D6241 Pontic Porc. Fused to Predom Base Metal 410.00
D6242 Pontic Porc Fused to Noble Metal 410.00
D6245 Pontic - porcelain/ceramic 460.00
D6545 Rtain Cast Mtl Res Bond Fix Prosth. 200.00
D6740 Crown - porcelain/ceramic 522.00
D6750 Crown Porc Fused to Hi Noble Metal 500.00
D6751 Crown Porc. Fused to Predom Base Mtl. 500.00
D6752 Crown Porc. Fused to Noble Metal 500.00
D6780 Crown-3/4 Cast High Noble Metal 500.00
D6790 Crown Full Cast High Noble Metal 500.00
D6791 Crown Full Cast Predom Based Metal 500.00
D6792 Crown Full Cast Noble Metal 500.00
D6930 Recement Bridge 52.00
D6970 Cast Post And Core In add. To Bridge Ret. 133.00
D6972 Prefab Post And Core in Add. To Bridge Ret. 105.00
D6973 Core Buildup for Retainer Including Pins 65.00
D6980 Bridge Repair by report 90.00
D7111 Coronal Remnants- Deciduous Tooth 46.00
D7140 Extraction, Erupted Tooth or Exposed Root 61.00
D7210 Surg. Removal of Erupted Tooth 90.00
D7220 Rem Impacted Tooth -Soft Tissue. 120.00
D7230 Rem Impacted Tooth- Part Bony 160.00
D7240 Rem Impacted Tooth-Complete Bony 195.00
D7241 EXTRACTION, COMPLETE BONY-DIFFICULT 205.00
D7250 Surgical Rem Resid Tooth Roots-Cutting Proc. 96.00
D7260 Oral Antral Fistula Close 184.00
D7270 Tooth Reimplant./Stabilization 174.00
D7272 Tooth Transplantation 155.00
D7280 Surg. Exos Imp/Unerupt- Ortho 80.00
D7281 Surg.Expos Imp/Unerupt-Aid Erup. 60.00
D7285 Biopsy of Oral Tissue Hard. 96.00
D7286 Biopsy of Oral Tissue Soft 108.00
D7310 Alveolopl in Conj with Extract.-per Quad 90.00
D7320 Alveolopl No Extract.- per Quad 110.00
D7340 Restibulop-Rdge Ext-Secnd Epthel 197.00
D7350 Vistbulop-Rdge Ext-Tissue Proc 187.00
D7410 Excision of benign leison up to 1.25c 254.00
D7411 Excision of benign lesion greater than 1.25 cm 434.00
D7440 Resection of malignant tumor 448.00
D7441 Excision of malignant tumor - Diam. > 1.25 cm 697.00
D7450 Rem Odont Cust/Tumor-Lesion to 1.25cm 150.00
D7451 Rem Odont Cyst/Tum -Les >1.25cm 170.00
D7460 Rem Nondodont Cyst/Tumor Lesion to 1.25cm 130.00
D7461 Rem Nodont Cyst/Tum > 1.25cm 300.00
Page 5 of 6 M1-CDT14
M1
EXHIBIT A - FEE SCHEDULE
D7471 Removal of mandibular tori per quadrant 263.00
D7472 Removal of torus palatinus 312.00
D7473 Removal of torus mandibularis 295.00
D7510 I&D Abscess Intraoral Soft Tissue 50.00
D7520 INCISION AND DRAINAGE OF ABSCESS-EXTRAORAL S 362.00
D7530 Incision and removal foreign body from soft tissue. 130.00
D7540 Removal of foreign body from bone (independent procedure) 144.00
D7550 Sequestrectomy for osteomylitis or abscess, superficial 90.00
D7560 Maxillary sinusotomy for removal of tooth fragment or foreign body 717.00
D7910 SUTURE OF RECENT SMALL WOUND UP TO 5CM. 116.00
D7911 Complicated suture - up to 5 cm 290.00
D7912 Complicated suture - greater than 5 cm 522.00
D7921 Collection and application of autologous blood concentrate product 640.00
D7960 Frenulectomy-Separate Proc. 160.00
D7970 Exc of Hyperplastic Tissue-per Arch 100.00
D7971 Excision of Pericoronal Gingiva 60.00
D7980 Sialolithotomy: removal of salivary calculus, intraorally 246.00
D7981 Sialolithotomy: removal of salivary calculus extraorally 246.00
D7982 Dilation of salivary duct 662.00
D7983 Closure of salivary fistula 632.00
D8210 Appliance to Control Harmful Habbits 250.00
D8220 Appliance to Control Harmful Habbits 250.00
D9110 Pall-Emergency Treatment Dent Pain -Minor P 35.00
D9220 General Anesthesia-First 30 Min 95.00
D9221 General Anesthesia each Add'l 15 min 30.00
D9230 Analgesia 30.00
D9240 Intravenous Sedation 85.00
D9241 IV Sedation 85.00
D9242 Intravenous conscious sedation/analgesia - each additional 15 minutes 43.00
D9248 Non-intravenous conscious sedation 25.00
D9310 Consult Diag. Svc by Nontreat Pract. 40.00
D9430 Office Visit Obs-Sched. Hrs-No Other Services 22.00
D9440 Office Visit - After Reg. Scheduled Hours 45.00
D9610 Therapeutic Drug Inj. by Report 18.00
D9940 Occlusal Guard by Report 210.00
D9942 Repair and/or reline of occlusal guard 60.00
D9951 Occlusal Adjustment -Limited 39.00
D9952 Occlusal Adjustment-Compl. 180.00
Page 6 of 6 M1-CDT14
D0120
D0150
D0210
D0330
D0220
D0274
D1110
D1120
D1203/1204
D1351
D1525
D2161
D7140
D7210
D3310
D3320
D3330
D4341
D2750
D6210
D5110
D5211
D8080
D8090
DESCRIPTION
$0
$0
$0
$0
$0
$0
$0
$0
$0
$10.00
$25.00
$0
$5.00
$25.00
$55.00
$120.00
$250.00
$25.00
$165.00
$165.00
$140.00
$120.00
$1975.00 †
$2175.00 †
DHMO 500COPAY
www.premierlife.com
ADAcode
Preventive Services
Periodic Oral Exam
Comprehensive Exam
Full Mouth Series ( FMX)
Panoramic
Periapical X-rays
Bitewings- four films
Adult Cleanings
Child Cleanings
Adult/Child Fluoride Treatment
Sealants 1st and 2nd Molars
Space Maintainers
Basic Services
Restorations - Amalgam Fillings
Extractions - Erupted tooth
Surgical Removal - Erupted tooth
Root Canal Therapy - Anterior
Root Canal Therapy - Bi-cuspid
Root Canal Therapy - Molar
Scaling & Root Planing, per quadrant
Major Services
Crowns
Bridges - per unit
Complete Denture - per arch
Partial Denture - per arch
Orthodontia (Child)
(Adult)
† based on 24 month treatment plan:additional ortho co-pays may apply, see
Certificate of Insurance for full break down
The Patient Charge Schedule is a summary of the covered services. Please check the Evidence of Coverage for full details. These services are covered only when covered dental services are performed by your Network Dentist, unless otherwise authorized by Premier Access Dental and Vision as described in your plan documents. The benefits shown are performed as deemed appropriate by the attending Primary Care Dentist (PCD) subject to the limitations and exclusions of the program. Enrollees should discuss all treatment options with their PCD prior to services being rendered.
Our Member Services Department is available Monday thru Friday 8 a.m. to 6 p.m. to answer questions and provide any help you may need at 866.650.3660
Plan Benefit Highlights• Posterior Composites• Oral Cancer Screening• Additional Cleanings• Cosmetic Procedures such as Labial Veneers & External Bleaching• Defined Fees for Metal Upgrades• Unlimited Benefits*• General Anesthesia and IV Sedation Covered
Why Choose Premier Access?R A-Rated by AM BestR Over 4000 Provider Access PointsR Over 20 years in the Managed Care Business
Premier Access Dental and Vision provides you and your family with quality dental benefits at an affordable cost. The program is designed to encourage regular dentist visits to maintain oral health. When enrolling, you select a contracted dentist to provide services for you and your family. The size of a provider network is meaningless without the assurance of quality care. Our dental providers consist of dental facilities that have been carefully screened for quality.
* refer to your Evidence of Coverage for details
Administered by Plan
DHMO500 BenefitsDental and Vision
rev 11/11
Exclusions and LimitationsThe following dental Benefits are excluded:1. Treatment which: a) is not included in the list of Covered Services; b) is not Dentally
Necessary; or c) is Experimental or Investigational Service.2. Appliances, inlays, cast restorations, crowns, or other laboratory prepared restorations
used primarily for the purpose of splinting.3. Services, supplies and appliances related to the change of vertical dimension, restoration
or maintenance of occlusion, splinting and stabilizing teeth for periodontic reasons, bite registration, bite analysis, attrition, erosion or abrasion, and treatment for temporoman-dibular joint dysfunction (TMJ), unless a TMJ benefit rider was included in the policy.
4. Replacement of a lost or stolen appliance including but not limited to, full or partial dentures, space maintainers and crowns and bridges.
5. Educational procedures, including but not limited to oral hygiene, plaque control or dietary instructions, unless specifically listed as a covered procedure on Schedule A.
6. Missed dental appointments. A fee of $25 may be charged by your Primary Care Dentist for failure to cancel an appointment without 24 hours prior notification.
7. Personal supplies or equipment, including but not limited to water piks, toothbrushes, or floss holders.
8. Treatment for a jaw fracture.9. Services or supplies provided by a dentist, dental hygienist, denturist or doctor who is:
a) a close relative or a person who ordinarily resides with You or an Eligible Dependent; b) an employee of the employer; c) the employer.
10. Hospital or facility charges for room, supplies or emergency room expenses, or routine chest x-rays and medical exams prior to oral surgery.
11. Services and supplies obtained while outside the United States, except for Emergency Care.
12. Services or supplies resulting from or in the course of your or your Eligible Dependent’s regular occupation for pay or profit for which you or your Eligible Dependent are entitled to benefits under any Workers’ Compensation Law, Employer’s Liability Law or similar law. You must promptly claim and notify Us of all such benefits.
13. Any Charges which are:a. Payable or reimbursable by or through a plan or program of any governmental agency,
except if the charge is related to a non-military service disability and treatment is provided by a governmental agency of the United States. However, We will always reimburse any state or local medical assistance (Medicaid) agency for Covered Services and supplies.
b. Not imposed against the person or for which the person is not liable.c. Reimbursable by Medicare Part A and Part B. If an Eligible Person at any time was
entitled to enroll in the Medicare program (including Part B) but did not do so, his or her Benefits under this policy will be reduced by an amount that would have been reimbursed by Medicare, where permitted by law. However, for Eligible Persons insured under employers who notify Us that they employ 20 or more employees during the previous business year, this exclusion will not apply to an actively at work employee and/or his or her spouse who is age 65 or older if the employee elects coverage under this policy instead of coverage under Medicare.
14. Services and supplies provided primarily for cosmetic purposes, except as specified in Schedule A.
15. Services and supplies which may not reasonably be expected to successfully correct the Member’s dental condition for a period of at least three years, as determined by Us.
16. Orthodontic services, supplies, appliances and orthodontic-related services, unless an orthodontic rider was included in the policy.
17. Extraction of asymptomatic, pathology-free third molars (wisdom teeth).18. Therapeutic drug injection.19. Correction of congenital conditions or replacement of congenitally missing permanent
teeth not covered, regardless of the length of time the deciduous tooth is retained.20. General anesthesia or intravenous/conscious sedation, except as specified in Schedule A. 21. Excision of cysts and neoplasms, except as specified in Schedule A.22. Osseous or muco-gingival surgery, except as specified in Schedule A.
23. Restorative procedures, root canals and appliances which are provided because of attrition, abrasion, erosion, wear, or for cosmetic purposes, except as specified in Schedule A.
24. Services and supplies provided as one dental procedure, and considered one procedure based on standard dental procedure codes, but separated into multiple procedure codes for billing purposes. The covered charge for the services is based on the single dental procedure code that accurately represents the treatment performed.
25. Replacement of stayplates. 26. Dispensing of drugs not normally supplied in a dental office.27. Malignancies.28. Additional treatment costs incurred because a dental procedure is unable to be performed
in the dentist’s office due to the general health and physical limitations of the Member.29. The member will be responsible for the actual metal fees for any procedure involving the
use of noble, high noble, or titanium metal.30. Implant-supported dental appliances, implant placement, maintenance, removal and all
other services associated with dental implants.31. Dental services that are received in an Emergency Care setting for conditions which are
not emergencies if the subscriber reasonably should have known that an Emergency Care situation did not exist.
32. Dental expenses incurred in connection with any dental procedures started after termination of coverage or prior to the date the Member became eligible for such services.
Limitations of Other Coverage:1. This dental coverage is not designed to duplicate any Benefits to which Members
are entitled under government programs, including CHAMPUS, Medi-Cal or Workers’ Compensation. By executing an enrollment application, a Member agrees to complete and submit to the Plan such consents, releases, assignments, and other documents reasonably requested by the Plan or order to obtain or assure CHAMPUS or Medi-Cal reimbursement or reimbursement under the Workers’ Compensation Law.
2. Benefits provided by a pediatric dentist are limited to children under six years of age following an attempt by the assigned Primary Care Dentist to treat the child and upon Prior Authorization by Premier Access Dental and Vision, less applicable Copayments.
Diagnostic and Preventive Benefits Limitations • Bitewing x-rays are now limited to two series within any 12-month period. • Full mouth and panoramic x-rays are now limited to once every 3 years, unless
medically necessary. • Prophylaxis services (cleanings) are now limited to two per 12-month period. • Dental sealants are now limited to children through the age of 15 years. Restorative Dentistry • Covered services now include posterior composite fillings. Periodontics • Periodontal maintenance is now limited to 2 treatments per 12 months. Crown and Fixed Bridge • The plan now covers treatment plans in excess of 5 units. There is an
additional copayment of $125 per unit for any treatment for 7 or more units. • The plan covers porcelain restorations on posterior teeth for an additional
copayment of $75 per unit. Prosthodontics • The new plans include an exception to the 5 year replacement limitation to
situations where there has been additional loss of natural functioning teeth.
rev 01/12
Dental and Vision
Premier Advantage
Employee Plan Information
FLEXIBLE DENTAL PLANS to meet your changing needs
Choice in Plan Type:The Premier Advantage plan allows you to select either a Dental Health Maintenance Organization (DHMO) managed care plan or a Dental Preferred Provider Organization (PPO) plan.
Flexibility to Change Plans:With the Premier Advantage plan, you may switch from the DHMO to the PPO plan or vice versa throughout the year. You and your dependents must be enrolled in the same plan type, either DHMO or PPO. However, within each plan, each covered dependent may have a different primary care dentist. If you decide to switch between plans, simply send a secure email to [email protected] or contact our Customer Service Department at 888-715-0760. If the change request is made by the 25th of any month, the change will become effective the first of the following month. Note: Plan changes may only be requested by the employee or the employer on behalf of the employee.
Benefits: • Choose the DHMO plan and you will generally have less of an out-of-pocket expense and get the greatest level of coverage.
• Choose the PPO plan and enjoy the freedom to choose any dentist. Get the greatest level of PPO coverage by choosing one of our quality Premier Choice Network (PCN) or Preferred Provider Network dentists.
• Switch between plans every month or stay in the plan you initially selected. The choice is yours.
How the Program works:First, you choose which plan you want to enroll in: DHMO or PPO. See our online directory at www.premierlife.com for participating providers in our DHMO Network, Premier Choice Network (PCN), or our Preferred Provider Network.
Once enrolled, follow the rules of your plan (DHMO or PPO). During the year, you are free to switch between the two plans. To request a plan change simply send a secure email to [email protected] or contact our Customer Service Department at 888-715-0760 by the 25th of the month to make your change effective the first of the following month. Remember, you and your dependents must be enrolled in the same plan.
Your Covered Dental Services Your Premier Advantage plan design offers you coverage for a broad range of dental services in both the DHMO and PPO plan options, including:
• Preventive Services (exams, cleanings and x-rays). The DHMO plan includes additional cleanings and adult fluoride.
• Basic Services (fillings, stainless steel crowns and extractions). The DHMO plan includes coverage for posterior composites (white fillings on back teeth).
• Major Services (crowns, bridges and dentures). The DHMO plan includes coverage for specific cosmetic procedures, nitrous oxide, certain mouth guards, and more.
Specific Covered Services and Supplies may fall under a different category than what is stated above. Age and frequency limits may apply to some services. Refer to your Schedule of Benefits for details on benefit levels and covered services.
What is not Covered?Below is a partial list of the charges and services the Premier Advantage plan does not cover. For a complete list of exclusions and limitations, see your plan documents.
• Dental services that are primarily cosmetic in nature (except as specified in the DHMO plan).
• Experimental services, supplies or procedures.
• Treatment of any jaw joint disorder, such as temporo-mandibular joint dysfunction (TMJ) (except as specified in the DHMO plan or if your plan sponsor has included additional coverage).
• Replacement of lost, missing or stolen appliances and damaged appliances.
• Services that are not dentally necessary for diagnosis, care or treatment.
• All other limitations and exclusions included in your plan documents.
An option that allows you to move between the dental hmo and ppo plans as your needs change.
Life doesn’t stand still...premier advantagelets you take control.
DHMO Plan Overview
The DHMO out-of-pocket expenses are generally lower than the Dental PPO plan.
How the plan works:• Copayments (a dollar amount) apply to certain
treatments.
• There are no calendar year maximums, no deductibles and no claims forms.
• Routine dental care is provided by a Primary Care Dentist (PCD) who participates in the Premier Access DHMO plan.
• You must have a PCD assigned to you in order to be covered for routine dental care. Each member of your family may choose a different PCD.
• You will receive an ID card.
• Your PCD will submit a referral request to Premier Access when specialty services are necessary.
• Your plan includes orthodontic benefits for adults and children. Refer to the Schedule of Benefits for covered services and copayments.
• Emergency Care
❖ Call your PCD if you require emergency care.
❖ If you are outside of your service area, call Premier Access’ Customer Service Department at the toll-free number on your ID card.
PPO Plan Overview
The Dental PPO plan provides more flexibility in choosing a dentist.
How the plan works:• Pay coinsurance (a percentage of the covered charge)
and deductibles to your dentist for covered charges. Your coinsurance will generally be lower if you visit a participating provider.
• Annual maximums will apply.
• Choose any licensed dentist.
• If your dentist participates in the Premier Choice Network (PCN) or the Preferred Provider Network, your payment will be based on negotiated fees and out-of-pocket costs will generally be lower than a non-participating provider. If your dentist is a PCN provider, your plan provides a higher level of coverage.
• You will receive an ID card.
• When you visit a participating dentist, your dentist submits the claim for you. If you visit a non-participating dentist, either you or your dentist submits the claim forms.
• Participating dentists are not permitted to charge you more than their contracted fee for covered services.
• No referrals are needed for specialty care. You are free to choose any specialist for a covered expense. See your Schedule of Benefits for details on benefits and limitations.
• Your plan may or may not include orthodontic benefits. If included, a lifetime maximum will apply.
• Emergency Care
❖ See any licensed dentist if you require emergency care.
❖ You may be required to submit claim forms.
If you would like to change your benefit plan, please call customer service at: 888.715.0760
If you would like to change your benefit plan, please contact Customer Service at:
Premier Advantage gives you the freedom to switch back and forth between each plan.
DHMONo Calendar Year Maximum
No Waiting Periods
Little or No Copayment
Panel of Dentists
Orthodontia Coverage for Adults & Children
PPOChoice of any Licensed Dentist,
Including Specialists
Maximize Your Benefits With a PCN Provider
No Referral Required for Specialty Services
Note: The information provided here is intended only to show the highlights of the dental plan and is not a complete description of the plan. The plan is governed by the official plan document and/or insurance contract where applicable. If there is a discrepancy between the information provided here and the plan document and/or insurance contract, the plan document and/or insurance contract will prevail. Premier Access PPO benefits are underwritten by Premier Access Insurance Company, Sacramento, CA. “Dental HMO” is used to refer to product designs that include “Specialized Health Care Service Plans” in California, by Access Dental Plan, a California Corporation.
TEL 888.715.0760 (toll free)
EMAIL [email protected]
WEB www.premierlife.com
If you are in the middle of treatment, you are required to complete treatment in progress prior to electing to switch to a new plan.
rev 01/12
Customer Service: 888-715-0760
Dear Premier Access Member, As your dental insurance carrier we are dedicated to get you the information you need promptly. This is why we have developed our website to assist in finding the Provider who is best for you. If you have not already registered as a member, please find instructions at the bottom of the page on how do so. You don’t need to be registered to search for providers; however, your search results will be limited to 50 providers. Following is a guide to finding the right Dentist for you. Find a Provider
1. Log onto our website (www.premierlife.com). 2. Click on “Find a Dentist”. 3. From here you have the option to perform a Quick Search OR an Advanced Search. 4. To perform a Quick Search it is important that you enter the information marked with an asterisk:
a. In the City, State OR Zip field you must enter either a City & State OR a Zip Code. (If you’re signed in as a member, your home zip code will automatically populate in this field)
b. Next, select a Commercial Plan from the drop down menu. (If you’re signed in as a member, the plan you are currently enrolled in will automatically populate in this field).
c. Then click “SEARCH” 5. Once you have clicked the “SEARCH” button the website will display the provider listing. You have the option
to print or email the directory. To perform a new search, simply enter another City & State OR Zip Code or click on Advanced Search.
6. To perform an Advanced Search it is important that you enter the information marked with an asterisk: a. In the City, State OR Zip field you must enter either a City & State OR a Zip Code. (If you’re signed in
as a member, your home zip code and street address will automatically populate in this field). To search by County, simply enter the County in the corresponding field. (If you’re signed in as a member, the pre-populated home zip code and street address will disappear as soon as you click on the County field).
b. Next, select a Commercial Plan from the drop down menu. (If you’re signed in as a member, the plan you are currently enrolled in will automatically populate in this field). Then select the Network otherwise the search will default to PCN & PPO Network.
c. Next, select the Specialty otherwise the search will default to All Dentists. If you select Dental HMO as your plan, the Specialty will default to General Practitioner. For DHMO plans you cannot select a Specialist, you need to be referred to Specialist by your Primary Care Dentist (PCD).
d. Next, select the Distance otherwise the search will default to 10 miles. e. Then click “SEARCH” or for an even more Advanced Search, you can enter the dentists name in step
5 and/or indicate additional search criteria in step 6. 7. You can change the order of the provider listing by selecting a sort option from the “Sort By” drop down menu. 8. Another great feature is the “Look Inside” addition to our website. Click on “Look Inside” and you’ll see things
such as Photos/Videos, Profile, Maps/Directions, Reviews. If you’re signed in as a member, you can write a review.
Registration Instructions
1. Have a copy of your Premier Access dental card in front of you. 2. Log onto our website (www.premierlife.com). 3. Click on “Register Here”. 4. Select User Type as Member. Then you will need to select one of the commercial plans. Either Dental PPO or
Dental HMO 5. Enter the information requested:
a. The member ID number must be entered exactly as it appears on your card (including the last 00) b. Member’s full date of birth (mm/dd/yyyy i.e 12/23/1975)
6. If you’ve entered the information and the system does not recognize you, then the information you’ve entered does not match what is in our system. If this occurs, please contact Premier Access at the phone number listed above for further assistance.
7. If you enter the information and the next screen asks you for your email address, then you have entered the information as it appears in our system and you may continue. Please enter your email address. This will be used to email your login and password information should you forget it in the future.
8. Now you can choose your own username and password. Please make sure to follow the character instructions to the right of the screen. You also must choose a security question and answer.
9. Accept the terms and conditions and click “Next”. A message will pop up stating that you have successfully registered online. Now you’re ready to administer your dental insurance online. Should you need additional assistance, please do not hesitate to contact us.
Premier Access Insurance Company Corporate Headquarters
8890 Cal Center Drive, Sacramento CA 95826 www.PremierLife.com Customer Service: 888-715-0760
Dental and Vision
Be Wise and Pre-Authorize!!!!When you take your automobile in for service, the mechanic/shop is required to provide a written estimate. An estimate details needed repairs and their respective costs. As a result, you understand the scope and cost of the repairs before services are rendered and you are billed. Isn’t that an essential piece of information needed to conduct potentially costly business?
PRIOR AUTHORIZATION is the dental version of an automobile estimate. Members receiving treatment in excess of $300.00 should ask their provider to submit a pre-authorization to Premier Access. This will prevent any surprises that may result from expensive treatment and empower the member to find a comparable alternative if necessary.
Simply ask your provider to provide you with a prior authori-zation. Receiving a Prior Authorization is your responsibility!
Education-PreAuthorize_F.pdf 1 8/22/11 1:39 PM
Access Your Benefits On The Go
You are no longer tied to your laptop or computer to access your Premier Access account information. With our new mobile apps you can:
➤ Access Benefit information which you can email/ fax to the dentist’s office
➤ Find a Dentist near you
➤ Pull up your ID card (handy when you’re at your dentist’s office)
➤ Contact Customer Service
*Please Note: Mobile app is not available for members under the following programs: Geographical Managed Care, Los Angeles Pre- Paid Health Plan, Healthy Families Program, Healthy Kids Santa Barbara, and UTAH Children’s Health Insurance Program.
Access your personal Premier Access account from your iPhone, iPad, or Android … anytime, anywhere
It’s safe; it’s secure; and it’s easy.
To access your information from our mobile apps, please use your www .premierlife .com username
and password.Visit www.PremierLife.com to set up your
account from your home computer.
Medical • Dental • Vision
Logon at www.premierlife.comYou have access to your claims information, can update your address, find a dentist in your neighborhood, check out your benefits, find information on dental care, print an ID card and nominate a dentist you’d like us to invite to join our network. All in just a couple of clicks- 7 days a week - 24 hours a day.
After-hours callsCall us anytime – day or night – to check your eligibility, have a benefits schedule faxed to you or request a replacement ID card or provider directory. After hours, an automated service will provide you with calling options. You can also get emergency information through this service.Just call 888.715.0760, toll free.
Customer Service RepresentativeYou can reach a Premier Access representative Monday through Friday, 8am to 6pm. Friendly and knowledgeable representatives will help you with any benefit questions or assist you if you would like to change dentists.
Want information instantly?
You’ve Got It!
… providing you with the information you need, when you need it.
Information at your fingertips on your mobile device. You can receive your benefit information through our smart phone apps!
You can also email us at [email protected]
888.715.0760
Dental and Vision
Preferred Provider Nomination Form
I would like to nominate my dentist for inclusion in the Premier Access Preferred Provider network. I understand that the Premier Access retains final authority for approving membership in the provider network. I also understand that Premier Access may use my name when contacting my dentist and inform him / her of my desire for them to join the network.
NOTE: This form does not serve as an enrollment form for dental insurance, or to register with the dental office as a patient.
Date: ____________________
Patient s Name: __________________________________________________________
Employer: ______________________________________________________________
Telephone: ______________________________________________________________
Dentist: ________________________________________________________________
Name: __________________________________________________________________
Address: ________________________________________________________________
________________________________________________________________
________________________________________________________________
Telephone: ______________________________________________________________
Specialty: ______________________________________________________________
If you have any questions about participating in Premier Access' provider network, please do not hesitate to contact us at: 800.640.4466
Please submit form to: Premier Access Network Operations P.O. Box 659010 Sacramento, CA. 95865-9010 Or FAX to: 916-646-9000
Medical • Dental • Vision
Premier Access Insurance CompanyP.O. Box 659010
Sacramento, CA 95865-9010WWW.PREMIERLIFE.COM
FOR INTERNAL USE ONLY reciffO ycavirP ot nevig lanigiro etaD yB droceR s’rebmeM otni deretnE devieceR etaD
HIPAA AUTH – PA (01/12)
AUTHORIZATION TO USE & DISCLOSE HEALTH INFORMATIONName of Member:____________________________________________ I.D. Number: ____________________________
Address of Member: _________________________________________________________________________________
I authorize Premier Access Insurance Company to use and disclose a copy of the specific health and dental information described below.
Information consisting of: (Check all that apply.)
Eligibility Benefits Claims Prior Authorizations/Specialty Referrals
Other (Please specify) _______________________________________________________________________
Name of the Person(s) or Organization(s) to whom you authorize us to use or disclose your information:
Please check all that apply, and list the name or organization:
Spouse ______________________________________ Mother ____________________________________
Employer _____________________________________ Father ____________________________________
Child ________________________________________ Other _____________________________________
For the purpose of: (Describe intended use or purpose of this disclosure)
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Expiration of Authorization: (For how long do you wish this Authorization to last)
1 year 3 years 5 years No expiration Other ____________________________________
If we are requesting this Authorization from you for our own use and disclosure or to allow another health care provider or health plan to disclose information to us: • We cannot condition our provision of services or treatment to you on the receipt of this signed authorization; • You may inspect a copy of the protected health information to be used or disclosed; • You may refuse to sign this Authorization; and • We must provide you with a copy of the signed authorization. You have the right to revoke this Authorization at any time, provided that you do so in writing and except to the extent that we have already used or disclosed the information in reliance on this Authorization. Unless revoked earlier or otherwise indicated, this Authorization will expire one year from the date of signing or shall remain in effect for the period reasonably needed to complete the request.
I have reviewed and I understand this Authorization. I also understand that the information used or disclosed pursuant to this Authorization may be subject to re-disclosure by the recipient and no longer be protected under federal law.
By:___________________________________________________________ Date: __________________________ Signature of Member (or authorized representative, if Member is a minor)
Printed Name of Authorized Representative _______________________________________________________ Relationship to Member _______________________________________________________________________
Please mail this form to the above-mentioned address to the attention of Customer Service. You may also FAX the form to 916.646.9000 to the Attention of Customer Service.
Dental and Vision
Use this form for a new enrollment or a change to an existing enrollment. Please complete in blue or black ink. Mail to: Premier Access Membership Accounting, P.O. Box 659020, Sacramento, CA 95865-9020 or fax to: 877.648.7748
FORM : 1081 03-12
Group Number: Coverage Type: PPO DHMO
Effective Date of Enrollment/Change:
Reason for Enrollment Form
New Enrollment/New Hire Qualifying Event (Attach supporting documentation) Late Enrollee (Subject to Late Enrollee Waiting Period)
Add Dependent (including spouse and registered domestic partner)Qualifying Event: _______________________________Date of Qualifying Event: _________________________
Change of Address Terminate Dental Coverage, Subscriber & Dependent(s)
Terminate Dental Coverage, Dependent(s) Only Change in Other Dental Insurance (Please see reverse side)
Other (Specify: ___________________________________)
Subscriber (Employee) Information
Social Security Number: Date of Hire:
Last Name: First Name: MI:Street Address: City: _______ State: Zip: _____________Home Phone: ( ) E-mail Address:Date of Birth: Sex: M F Married? Yes No Children? Yes NoEmployer (Company) Name:
Job Title: Division/Class: Hours Worked Per Week: Preferred Spoken Language: Preferred Written Language:Ethnicity (optional): ______________ Race (optional):Managed Care Only: Please select a Primary Care Dentist (PCD) from the provider directory for yourself and each of your family members. Fill in the Provider ID number and Office ID number in the appropriate areas. If a selection is not made, a PCD will be assigned for you.
Primary Care Dentist No. Primary Care Dentist Office No.
Dependent Information New Enrollment/New Hire: Complete this section for all dependents you are choosing to enroll.Add Dependent: Complete this section only for the dependents you are adding to your existing enrollment.Terminate Dependent Coverage Only: Complete this section only for dependent(s) you are choosing to terminate.
Relation to Subscriber Last Name First Name & MI Date of Birth** Sex(M/F)
Primary Care Dentist Office
ID #Primary Care Dentist ID #
Spouse/ or Reg. Domestic PartnerChild
Child
Child
Child
Child
To the best of my knowledge or belief, I have answered truthfully and completely the information requested on this application, including the information on the back of this application. I understand that Premier Access Insurance Company reserves the right to rescind or terminate coverage if any material misrepresentation is made in this enrollment application. I have read and agree to the notice on the back of this form.
MANDATORY BINDING ARBITRATION: Premier Access Insurance Company uses binding arbitration to settle disputes, including to settle claims of dental malpractice. The insured understands and agrees that if a dispute arises in connection with this policy, the parties waive the right to a jury trialand must settle the dispute through binding arbitration. The Premier Certificate of Insurance contains a provision that further addresses this issuePremier Access Insurance Company does not use binding arbitration in connection with any dispute that an insured’s life insurance coverage.
Employee Signature: Date:
Dental and Vision
** Dependent child eligibility requirements are defined by the Employer Group Policy. Supporting documentation of dependent eligible status must be submitted with this form for dependent children age 19 or over for the enrollment to be processed and claims paid.
EMPLOYEE ENROLLMENT/CHANGE FORM
EMPLOYEE ENROLLMENT/CHANGE FORM
03-12
The Premier Access Vision Plan is administered by MESVision® and is underwritten by the Gerber Life Insurance Company of White Plains, NY.* All references to “Premier” herein refer to Premier Access Insurance CompanyPRE-ENR-1081
Other Dental Coverage
Do you or your dependents have other dental coverage? Yes No (If yes, complete the information below.)
Other Dental Coverage Information
Name of Insured: Social Security Number:
Insured’s Employer: Name of Insurance Carrier:
Employer’s Street Address:
City: State: Zip: Phone: ( )
Are your dependent children enrolled under your spouse’s (or registered domestic partner) dental plan? Yes No
CALIFORNIA LAW PROHIBITS AN HIV TEST FROM BEING REQUIRED OR USED BY HEALTH INSURANCE COMPANIES AS A CONDITION OF OBTAINING HEALTH INSURANCE COVERAGE. THEREFORE, PREMIER ACCESS INSURANCE COMPANY WILL NOT REQUIRE THAT AN HIV TEST BE REQUIRED AS A CONDITION OF OBTAINING COVERAGE. IN ACCORDANCE WITH CALIFORNIA HEALTH AND SAFETY CODE SECTION 120980, PREMIER ACCESS INSURANCE COMPANY COMPLIES IN ALL RESPECTS WITH THE PROHIBITION AGAINST THE UNAUTHORIZED DISCLOSURES OF AN HIV TEST.
I, on my behalf and on behalf of my dependent(s) on this enrollment application, hereby (1) request coverage for the group insurance for which I am or may become eligible; (2) authorize my employer to make the necessary deductions for the contributions, if any, required for the insurance, or agree that the contributions be added to my dues; (3) state that I became a full-time employee on the date stated on the reverse, and do currently work the number of hours per week stated on the reverse, (4) agree to be bound by benefits, copayments, deductibles, exclusions, limitations, and other terms and conditions of the Premier* Certificate of Insurance, (5) agree that if I or my dependents receive dental services after my coverage is terminated or lapses, that I am responsible to reimburse Premier for any unrecovered payments made by Premier for such services, and (6) understand that verification of eligibility by Premier does not guarantee payment of claims and that retroactive eligibility changes supercede verifications of eligibility.
DENTAL RELEASE: I, on my behalf and on behalf of my Dependent(s) listed on this Enrollment Application, hereby authorize Premier to release dentalinformation to official government agencies and to other individuals when required under appropriate federal or state law, or pursuant to legal process and to release and obtain dental information to or from other appropriate agencies and providers for the provision of necessary dental services and supplies covered by Premier. If you request, Premier will provide a copy to you of any information it discloses to third parties regarding your dental information. This Dental Release authorization shall remain in effect thirty months from the date the application is signed. This Dental Release authorization solely provides authorization of Premier to release dental information to official government agencies and to other individuals when required under appropriate federal or state law, or pursuant to legal process and to release and obtain dental information to or from other appropriate agencies and providers for the provision of necessary dental services and supplies covered by Premier. The dental information is being collected by Premier solely for the specific purpose of premium underwriting..
RIGHT OF REIMBURSEMENT: I, on my behalf and on behalf of my Dependent(s) listed on this Enrollment Application, hereby agree that in the event any dental services provided to me or my Dependent(s) covered by Premier are the primary financial responsibility of another party, because of other dental coverage , I will fully inform Premier and will execute such assignments, liens or other documents which may be necessary to enable Premier to recover the value of services and supplies provided
NOTICE: Any person who, with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud and may be subject to fines and confinement in prison.
* All references to “Premier” herein refer to Premier Access Insurance CompanyPremier Group Insurance Individual Waiver Statement Form
PRE-EE-WAV- 01-2012
INDIVIDUAL WAIVER STATEMENT(Use this form for employees electing to waive coverage for themselves and/or their dependents.)
Current Group Number:Waiver Statement: I have been given the opportunity to enroll in the group dental plan my Employer has obtained from Premier* and, after consideration, have decided to waive coverage for:
Myself and all Dependents My Spouse
My Dependents (Spouse and Child(ren)) My Dependent Child(ren)
Employee Information:Social Security Number:
Last Name: First Name: MI:
Street Address:
City: State: Zip: Home Phone:
E-mail Address:
Employer (Company) Name:
Reason for Waiver: I am declining coverage because I am covered under another dental plan not affiliated with my current Employer.
This coverage is provided through: My Spouse’s Employer Plan (Employer’s Name):
Military Individual Policy Medicare/Medicaid Other: Insurance Carrier’s Name:
Coverage is being declined for my Spouse because he/she is covered under another dental plan.Spouse’s Name: Insurance Carrier’s Name:
Coverage is being declined for my Child(ren) because he/she is covered under another dental plan.Child(ren)’s Name(s): Insurance Carrier’s Name:
Coverage is being declined for my Spouse and/or Child(ren). They are not covered under another dental plan.List Name(s):
I understand that if I later decide to apply for coverage for myself or any dependents for which I am waiving coverage at this time, Premier mayconsider me a late enrollee and may impose a Benefit Waiting Period. I also understand that at the time of my subsequent application for coverage, I will have to comply with the applicable group dental Policy requirements for eligibility and enrollment.
You will not be considered a late enrollee if one or more of the following applies:
1. You or Your waiving Dependents were covered under another dental plan at the time of waiver, you are no longer covered under the other dental plan for one of the reasons stated below and you request enrollment in Premier within 30 days after termination of coverage or Employer contribution under the other dental plan.
a. Termination of employment;b. Change in employment status;c. Termination of the other plan’s coverage;d. Cessation of an employer’s premium contribution toward an employee’s or dependent’s coverage; ore. Death of or divorce from the individual through which the waiving individual was covered as a Dependent.
2. A court orders coverage be provided for a spouse or child of an insured Employee and request for enrollment under Premier is made within 30 days of the issuance of the court order.
3. You are employed by an Employer that offers multiple dental plans and You elect a different plan during an open enrollment period.
Employee Signature: Date:
Dental and Vision