9809095-1

 

This is NOT A DENTAL INSURANCE POLICY!

This is a DISCOUNT PROGRAM designed for you, your family,

employees or anyone with dental needs!

Plan offers:

2 FREE dental exams per year

2 FREE basic cleanings per year*

1 FREE set of digital x-rays

 

20% to50% DISCOUNT on any other treatment including root canals,

fillings, bleaching, crowns, bridges, dentures, deep cleaning and more.

This is a discount fee plan. THIS IS NOT DENTAL INSURANCE.

By paying an annual enrollment fee, you will be entitled to receive

dental services at reduced rates.

Individual coverage $99.00 for 12 months coverage

 

Family coverage

$99.00 1st person

$35.00 each additional member

register on the same day

$55.00 each additional member

register any other day

Does not apply to periodontal

treatment such as Scaling and

Root Planing, (deep cleaning).

Dental Procedure                                        Regular Price                               You Pay

Routine Exam                                                        $58                                              $0

Comprehensive Exam X-Rays                              $88                                              $0

Adult Cleaning                                                        $118                                           $0

Child Cleaning                                                        $67                                              $0

Tooth color filling 1 surface                                 $178                                            $83

Tooth color filling 2 surfaces                                $218                                           $108

Tooth color filling 3 surfaces                                $288                                            $143

Tooth color filling  4 surfaces                               $328                                            $151

Crown porcelain, M/B                                            $875                                            $645

Core buildup/pins                                                  $268                                            $131

Root canal aneterior                                              $688                                            $369

Root canal bicuspid                                                $788                                             $507

Root canal molar                                                   $945                                             $663

Full mouth debrid                                                  $190                                             $99

Scaling & root planning per 1/4                           $238                                            $129

Complete dent upper                                            $1280                                          $852

Complete dent lower                                            $2560                                          $1200

Combo denture ( upper/lower)                          $2560                                          $1200

Routine extraction                                                $189                                             $89

Surgical extraction                                               $268                                             $171

  1. Definitions. As used in this Description, “Eligibility” means

your right to receive dental services at reduced rates. Services

at the reduced rate set forth In this Description. “Specialist”

services” are periodontics, endodontics, orthodontics and oral

surgery. ‘Specialist’ is a dentist who pertains only a specialist service.

 

  1. Commencement of Services. Once you have read through

this Description you should complete the Enrollment Form

included in this brochure along with your payment for the one-

time processing and initial annual enrollment fee.

Payment may be made by check. cash, or credit card. Once your

Enrollment form and fees are received you will be eligible to

receive discounted pricing.

  1. Term and Termination of Services. Your right to receive

services will continue for one 1year from the time we receive your

initial annual enrollment fee. The termination date will appear on

your identification card. and will end on midnight on that date.

 

  1. Renewal of Eligibility. You can renew your right to receive

discounted fee services for an additional year by paying an

annual re-enrollment fee before your initial eligibility terminates.

The re-enrollment fee may be different from the Initial annual

enrollment fees and you will be told what the applicable fee is in

your renewal notice. Upon re-enrollment you will receive new

identification cards. The same procedure Will be used to re-enroll

for succeeding years.

  1. Cancellation of Services. You will have ten (10) days after you

receive your identification card to cancel your  eligibility and

receive a full refund of your enrollment fee. However, no

cancellation will be permitted if you received services during this

10-day period.

  1. Other Charges. There are no copayments, deductibles,

or other charges of any kind under this plan.

All that you have to do is pay your for the discounted services

that you or your eligible family members receive when you need them.

 

  1. Limitations and Exclusions. The following is a complete list of

all limitations and exclusions under this Plan:

It is your responsibility for payment of fees at the time you

receive service if you have dental insurance. We do not provide

insurance and do not coordinate benefits with any dental

insurance you or your family members may have. If you have

dental insurance, you should contact your dental insurer to see

what benefits will be paid.

Treatments not covered are fractures or dislocations, congenital

malformations, malignancies, cysts or neoplasms, or

Temporomandibular Joint Syndrome (TMJ). prescription drugs

and over the counter drugs. Prophylaxis (Basic Cleaning) is

limited to once every six months, which does not apply to a

periodontal deep cleaning, (SRP). Full mouth x-rays are limited

to once every 24 months. replacement of partial dentures is

limited to once every five years. Full upper and/or lower dentures

are not to exceed one each time in any five-year period.

Denture relines are limited to one per arch in any 12 month

period.