Texas 2009

Dental Plansfor Individuals, Families & Self Employed

When can I begin receiving dental care?Discount Plan• - can begin receiving benefits and dental care the day they enroll.Co-Pay & Co-Insurance Plans• - the policy and benefits become effective the 1st day of the month following the date we receive your enrollment.

How do waiting periods affect my dental care?Discount Plan• – There are no waiting periods.Co-Pay & Co-Insurance Plans• – No waiting periods for preventive care (cleanings, oral exams, etc). Waiting periods do apply to basic and major services; however, even before waiting periods are met, members pay lower contracted fees for all covered services from in-network dental providers.

What if my dental provider does not participate on a Dental Select network?Discount Plan• – No out-of-network discounts. Member must receive dental care from a Silver Network provider to receive discounts. Co-Pay Plans• – After deductibles and waiting periods are met, Co-Pay Plan members receiving dental care from a general dentist will receive an out-of-network benefit, which pays according to the Schedule of Co-Payments.Co-Insurance Plans• – After deductibles and waiting periods are met, all Co-Insurance Plans pay an out-of-network benefit, according to the plan fee schedule.

All charges over the plan payment will be the member’s responsibility.

Do I get benefits for orthodontia work?Discount, Co-Pay and Co-Insurance (Option 1) Plans• – From the plan’s effective date, all members receive a 20% discount on all covered orthodontic services when using an in-network dental provider.Co-Insurance (Option 2) Plans • – Members receive a 20% discount plus a 50% paid benefit (for children under 19) once the 24 month orthodontia waiting period is met, subject to plan maximums. Before the waiting period is met, all members receive a 20% discount on all covered orthodontic services when using an in-network dental provider.

What if I require services from a dental specialist?Most general dentists will perform specialist services. In the event one is needed, specialists include Endodontists, Periodon-tists, Pediatric Dentists, Orthodontists, Prosthodontists, and Oral Surgeons.

Discount Plan• – Members receive discounts on all services from in-network specialists.Co-Pay Plans• – Members receive a 20% discount on all services provided by an in-network specialist. No waiting periods or deductibles apply. Co-Insurance Plans• – After waiting periods and deductibles are met, members receive a paid benefit for covered services provided by both general dentists and specialists. In addition, you can save on out of pocket expenses when visiting an in-network provider.

What if I need services before my waiting periods or deductibles are met?Even before waiting periods and deductibles are met, members receive lower contracted fees for all covered •services from network providers.

Help Me Choose A Plan

Three easy ways to enroll:Enroll online at 1. www.dentalselect.com & waive the $15 enroll-ment fee, or call a Dental Select representative at 1-800-999-9789Fill out the attached enrollment form and return to Dental Select with 2. your $15 enrollment fee included Call your insurance agent3.

Why Dental Select?

Value of Dental InsuranceYou are twice as likely to receive regular dental check-ups with dental insurance. For every $1 you spend in preventive dental care you could save $8 to $50 in restorative and emergency treatment. Regular dental check-ups along with healthy teeth and gums not only saves you money, but will also:

Your Savings with Dental Select!

•Reduceyourriskofaheartattackupto150%•Reducetheriskofprematureandlowbirthweightbabiesby700%•Decreaseawoman’sriskofdevelopinggestationaldiabetes•Significantlyreducecomplicationsassociatedwithdiabetes•Decreasethemostcommonchronicchildhooddisease–toothdecay•Ensureearlydetectionandincreaseyourchanceofsurvivingoralcancer

Over 20 years of experience providing dental insurance to •individualsGuaranteed acceptance and renewal•Dental insurance experts•Community partner through the Sealants for Smiles program •whichappliessealantstoover4,700underprivilegedchildren each yearChoice of Discount, Co-Pay & Co-Insurance Plans with a wide •range of monthly premiums

Fast claims payment & accuracy•Cosmetic discount available for bleaching, veneers, etc.•Quality Contracted Providers • (as of Oct. 1, 2008)

ADA Code Description

Average Cost

Discount Plan

You Pay

Co-pay Gold Plan

(TX-3) You Pay

Co-pay Platinum

Plan (TX-3)

You Pay

Co-Insurance

Gold Option 1You Pay

Co-Insurance PlatinumOption 1You Pay

Co-Insurance

Gold Option 2You Pay

Co-Insurance PlatinumOption 2You Pay

D0120 Routine Checkup $37.18 $15.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

D1110 Adult Cleaning $73.51 $42.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

D1120 Child Cleaning $50.74 $30.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

D1203 Fluoride (age 14 & under) $25.81 $7.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

D2140 Filling - 1 surface (silver) $116.83 $43.00 $0.00 $0.00 $13.80 $17.70 $9.20 $11.80

D2391 Filling - 1 surface (white) $138.95 $69.00 $34.00 $34.00 $23.70 $25.80 $15.80 $17.20

D2750 Crown - porcelain $932.92 $482.00 $310.00 $349.00 $255.00 $283.50 $255.00 $283.50

D3330 Molar Root Canal $963.35 $380.00 $272.00 $392.00 $197.00 $280.00 $197.00 $280.00

D4341 Periodontic Root Planing $190.64 $103.00 $86.00 $99.00 $53.00 $64.00 $53.00 $64.00

D7111 Extraction of Primary Tooth $90.15 $50.00 $31.00 $32.00 $18.90 $20.70 $12.60 $13.80

D7210 Surgical Extraction $206.97 $88.00 $60.00 $80.00 $30.30 $37.20 $20.20 $24.80

Dental Insurance = Healthier YOU

Silver over 1,800 providers•Gold over 2,300 providers•Platinum Co-Pay over 3,000 providers•Platinum Co-Insurance over 6,400 providers•Over 58,000 providers nationwide • (Platinum Co-Insurance only)

Average cost shown is based on the most heavily populated zip codes for contracted providers in Texas. Your payment is subject to waiting periods, deductibles & plan maximums. Savings based on services performed by a contracted provider.

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9.

Access Discount Vision

If you would like a simple and carefree vision plan with savings of up to 40% at more than 40,000 independent providers and retail stores such as LensCrafters, Pearle Vision, Sears Optical, and Target Optical, this is the vision plan for you. Your entire family can be included, as long as they are also on your dental plan.

- No maximums - No waiting periods- No limits on number of visits- No claims to submit- No limits on amount of purchase

- All styles, sizes and materials are included- Includes contact lenses- Receive a discount of 5 - 15% on laser vision

correction surgery- Large nationwide panel of providers

access Vision FeaTures

The ACCESS Vision Plan is a fee for service discount plan, it is not an insured product. This program provides discounts only from a certain network of vision providers. The member is responsible to pay for all services but

will receive a discount from vision providers who are contracted on the Access Network.

summary oF Vision BeneFiTs

Vision Care Services Member Cost

Exam with Dilation as Necessary:* $5 off routine exam$10 off contact lens exam

Complete Pair of Glasses Purchase: frame, lenses and lens options must be purchased in the same transaction to receive full discount.

Standard Plastic Lenses: Single Vision Bifocal Trifocal Progressive

$50$70

$105$135

Frames: Any frame available at provider location 35% off retail price

Lens Options: UV Coating Tint (Solid & Gradient) Standard Scratch-Resistance Standard Polycarbonate Standard Anti-Reflective Coating Other Add-ons & Services

$15$15$15$40$45

20% Discount

Contact Lens Materials: (Discount applies to materials only) Disposable Conventional

N/A15% off retail price

Laser Vision Correction: Lasik or PRK

15% off retail price -or- 5% off promotional price

* Under contract, ACCESS Vision Providers may charge usual & customary rates for a comprehensive exam up to a contracted fee per region.

Discount Vision included for your entire family on every plan

Annual & Monthly Billing Options

MONTHLY payments are taken via automatic withdrawal or charge from:Checking or Savings account; or1. Credit or Debit Card. (Visa or Master Card)2.

Note: Premiums are drafted on the 16th of the month or the next 2 business days. On Co-Pay and Co-Insurance plans, premiums are paid one month in advance. For Discount plans, premiums are paid for the current month. When enrollments on Co-Pay or Co-Insurance plans are received after the 14th of the month, they will be charged for two months of premium (one for the month that the enrollment became effective and one for the month following) on the 16th of the month or the next business day; thereafter, they will be drafted for just one month.

ANNUAL Payments can be made by:Annual Check1. Credit Card Payment (Visa or Master Card)2.

Note: if annual payment is made by credit card, upon yearly renewal we will automatically charge the credit card 2 weeks in advance of the annual renewal date, unless a check is received before this time. At renewal, you can change to a monthly payment option.

How do I cancel?All cancelation requests must be received in writing. Your cancelation will be effective the first day of the month following the month your written request is received.

DenTal Plan exclusions

1. for services and supplies not listed in the Coverage Schedule, not recognized as essential for the treatment of the condition according to accepted standards of practice or considered experimental.

2. for services provided by Specialists whether Contracted or Non-Contracted. (Co-pay plans only)

3. for cosmetic procedures, including but not limited to veneers and bleaching of teeth and procedures performed primarily for cosmetic reasons.

4. for services related to, performed in conjunction with, or resulting from a non-covered procedure.

5. for charges in excess of the contracted Fee-for-Service schedule or the Reasonable and Customary rate, whichever applies.

6. for any treatment program which began prior to the date the Insured is covered under the Policy.

7. for crowns, inlays and onlays on teeth that can be restored by direct placement materials.

8. for the replacement of crowns, bridges, inlays, onlays or prosthetic appliance within 5 years from the date of last placement.

9. for service or supplies payable under any medical expense, auto or no-fault plan.

10. for any condition covered under any Worker’s Compensation Act or similar law.

11. for services applied without cost by any municipality, county or other political subdivision or for which there would be no charge in the absence of insurance.

12. for services that are applied toward the satisfaction of a Deductible, if any.

13. for services subject to a waiting period that were incurred during the waiting period.

14. for charges resulting from changing from one provider to another while receiving treatment, or from receiving treatment from more than one provider for one dental procedure to the extent that the total charges billed exceed the amount incurred if one provider had performed all services.

15. for hospital facility charges for any dental procedure, including but not limited to: emergency room charges, surgical facility charges, hospital confinement.

16. for drugs or the dispensing of drugs.17. for oral hygiene instruction; plaque control; acid etch;

prescription or take-home fluoride; broken appointments; completion of a claim form; OSHA/Sterilization fees (Occupational Safety & Health Agency); or diagnostic photographs (except for orthodontic purposes).

18. for implants; myofunctional therapy; athletic mouthguards; precision or semi-precision attachments; treatment of fractures, cysts, tumors, or lesions; maxillofacial prosthesis; orthognathic surgery; TMJ dysfunction; cleft palate; or anodontia.

19. for orthodontia, unless included within the Coverage Schedule.

20. for the replacement of a filling within 24 months of placement, unless for specific health reasons.

21. for composite, resin, or white fillings on posterior primary teeth. Benefit will be reduced to that of an amalgam or silver filling.

22. for the replacement of retainers. 23. for sealants not applied to permanent bicuspid or molar;

applied at age 15 or older; applied 3 years from a previous sealant application; applied to a decayed tooth.

24. for lab fees for higher metals or porcelain crowns, bridges, inlays or onlays.

25. for general anesthesia or IV sedation. (Co-pay plans only)26. for services to replace teeth that were missing (extracted or

congenitally) prior to the effective date of coverage on Our Plan. This limitation ends after 36 months of continuous coverage on the Plan. Abutment teeth will be reviewed for eligibility of prosthetic benefits. This exclusion does not apply if the device covers one or more natural teeth lost or extracted while covered under the Plan, or if the prosthetic device was in place when the policy became effective.

27. during travel or activity outside the United States.

No benefits will be paid:

TX2009 INDIVIDUAL 10/08

This insurance does not apply to the extent that trade or economic sanctions or other laws or regulations prohibit us from providing insurance, including, but not limited to, the payment of claims.

The benefits illustrated are in summary form only. They should not be construed as complete in and of themselves. They are only for comparison and in the case of discrepancy the plan documents apply. Please refer to the certificate for a complete description of benefits, limitations, and exclusions.

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DENTAL SELECT - CORPORATE OFFICE5373 S. GREEN STREET, 4th FLOORSALT LAKE CITY, UTAH 84123Toll Free (800) 999-9789Toll Free Fax (888) 998-8711

Age

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M M M MF F F F

Please Complete Both Sides

Choose your Plan (Choose only one)

Payment Options (Choose either Checking/Savings or Credit Card Paym

ent)

Discount PlanBilling Period: M

onthly (Withdrawn on the 16th or next 2 business days) Annual (Check or Credit Card)

Silver Netw

orkChecking or Savings (Include a $15.00 enrollm

ent fee with your payment)

Co-Pay PlansC

hecking Account (Include Voided C

heck) Savings Account (Include D

eposit Slip)

Gold N

etwork

Platinum

Netw

orkFinancial Institution:

Co-Insurance PlansR

outing Num

ber:

Option 1

Option 2

Account N

umber:

Gold N

etwork

Gold N

etwork

Credit Card Payment (Include your check for the $15.00 enrollm

ent fee)

Platinum

Netw

orkP

latinum N

etwork

VISA

MA

STE

RC

AR

D

Vision plan included with all dental P

lansA

ccount Num

ber: Exp. Date:

I wish to enroll in the plan I have selected. I authorize and agree to account deduction of

the required premium

.

Signature: Date:

Account H

older Nam

e:

Account H

older Signature: Date:

This authorization will rem

ain in effect until the financial institution has received and has had reasonable time to act on a w

ritten request from m

e to terminate this agreem

ent. I understand that I can stop a withdraw

al by notifying the financial institution at least three business days before the w

ithdrawal is m

ade. In the event of a withdraw

al error, I must prom

ptly notify the financial institution to preserve any rights I may have. P

lease direct billing inquiries to Dental Select, 5373 S. G

reen Street., 4th Floor, Salt Lake City,

UT 84123. I have read and understand the statem

ents above pertaining to the billing option. Your cancellation will be effective the first day of the m

onth following the m

onth your written request is received.

In the event there are insufficient funds when a draft is charged to m

y account, I agree to pay $25 NSF Fee. The 3rd returned check in any 12 m

onth period will result in the im

mediate cancellation of m

y policy. Dental Select reserves the right to deny m

e the ability to be reinstated on any Individual D

ental Select plan for two years.

AC

E USA

is the U.S. dom

estic operating division of AC

E Limited. Insurance products and services are provided by the U

.S. insurance underwriting com

panies and not by AC

E Limited. G

old and Platinum

plans of insurance are underwritten by A

CE A

merican

Insurance Com

pany.