Competitor Smile Dental pays benefits for each covered person in the following manner:
First, you meet the $50.00
Calendar Year Deductible per person.
(Maximum of three individual deductibles per family)
Then Competitor Smile
Dental pays a percentage
of covered expenses based on the Reasonable and
Customary (R&C) fees for those Covered Expenses. You can
select your own dentist.
| SERVICES | GOLD | SILVER | BRONZE |
|---|---|---|---|
|
Calendar Year Maximum (Per Person) |
$1,500 | $1,000 | $750 |
| Preventive: Exams, Cleaning, Fluoride Treatments | |||
| Year One | 100% | 100% | 100% |
| Year Two | 100% | 100% | 100% |
| Year Three and After | 100% | 100% | 100% |
| Waiting Period | None | None | None |
| Basic: X-rays, Fillings, Extractions and Oral Surgery | |||
| Year One | 20% | 20% | 20% |
| Year Two | 40% | 40% | 40% |
| Year Three and After | 60% | 60% | 60% |
| Waiting Period | None | None | None |
| Major: Crowns, Bridges, Dentures and Root Canals | |||
| Year One | 10% | 10% | No Coverage |
| Year Two | 25% | 25% | |
| Year Three and After | 50% | 50% | |
| Waiting Period | None | None | |
|
Calendar Year Maximum (Per Person) |
$1,500 | $1,000 | $750 |
Who is eligible for this
coverage?
This plan is offered to individuals and their spouse
ages 18 through 64 and their eligible dependents
(unmarried children from birth to age 19 or 23 if a
full-time student Ñ this is subject to state
requirements.) Coverage may also be obtained by
individuals and their spouse ages 65 and older.
When does my coverage
start?
Coverage starts on the effective date. The effective
date issued will begin on the 1st of the month (at 12:00
a.m.), following HPA, Inc.Õs receipt of the completed
Enrollment Form and payment of the first month of
premium.
What are my payment
options?
You can pay in monthly installments by check, credit
card, or auto bank withdrawal. We accept MasterCard,
Visa or Discover credit cards.
What services are covered?
Preventive Services
Routine oral examinations of mouth and teeth: 2 per calendar yearProphylaxis (cleaning, scaling and polishing teeth), 2 per calendar year
Topical fluoride, 1 per calendar year to age 16
Space maintainers (non-orthodontic)
Basic Services
Diagnostic X-rays
(full or panoramic), 1 in any 3 year period
Bitewing X-rays:
2 per calendar year
Simple extraction
of one or more teeth
Pin retention
of fillings
Fillings
(restorations) using amalgam, silicate, acrylic,
synthetic porcelain and composite filling materials
Antibiotic injections
administered by a Dentist
Oral surgery
and postoperative care for removal of one or
more teeth, extraction of tooth root, alveolectomy,
alveoplasty, frenectomy, excision for biopsy,
reimplantation or transplantation of a natural
tooth, excision of a tumor or cyst and incision and
drainage of an abscess or cyst
General anesthesia
and analgesic, including intravenous sedation for
oral surgery
Major Services
Periodontic services
Study models, 1 in a 3 year period
Crown build-up for non-vital teeth
Recementing and restoration of inlays, onlays and crowns
Recementing bridges
Repairs to full or partial dentures or bridges, one every 2 years
Prosthetic services (dentures or bridgework)
What is a Reasonable
and Customary Fee?
This plan reimburses you for covered dental expenses
based upon "Reasonable and Customary" fees.
Reasonable and Customary fees are charges that do
not exceed the general level of charges being made
by other providers of dental services in the
geographic area where the charge is incurred.
This site provides a
brief description of the benefits, exclusions and other
provisions of the policy or certificate Form Master
Policy #GH-1112-38090 issued to the Voluntary Group Trust. For a complete listing, see the policy or
certificate. Benefits may vary in different states. This
dental insurance plan may not be
available in all states. ©2003 HPA, Inc. All rights
reserved. S105121 (10/03)
