docBenefits Eligibility HOAMCO - Consolidated Personnel Services
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Benefits Eligibility HOAMCO - Consolidated Personnel Services
Benefits Eligibility HOAMCO New employees are eligible to enroll in Voluntary Benefits once they have completed their waiting period of 60-days. Employees should submit all completed enrollment forms to CPS by the end of their 30th day. The sooner, the better! Employees will be effective on the first of the month after completing their waiting period, providing CPS has received appropriate/completed enrollment forms no later than the last business day of preceding month. (ie: by 4/30 for a 5/1 effective date) A re-hire is the same as a new hire and must complete all new enrollment forms after completing their waiting period. If any employee does not enroll during the month of their eligibility, they must wait until *Open Enrollment—(The ONLY exception to enroll/cancel/make changes outside of an eligibility period or Open Enrollment is a “Qualifying Event” as determined by Cafeteria 125/IRS Law such as marriage, divorce, birth, death, loss of or getting new coverage.) The change and proof of that change must be submitted to CPS within 31 days of the “Qualifying Event” Open Enrollments: * February-Dental & July-Vision* Employees must work at least 30 hours a week and seasonal employees are not eligible. CPS can never activate nor terminate coverage retroactively (Terminations will occur at the end of this month and activations will occur the first of next month.) CPS collects premiums a month in advance, ie: deductions in Sept. pay periods for Oct. premiums, for all benefits. Premiums are deducted between the remaining pay periods in this month. Rates in this packet are your monthly cost and already reflect the amounts HOAMCO pays towards the employee portion. I have received and understand the above requirements. Employee name _____________________ Signature ____________________ Date _________ 80% ** 60% ** 40% ** Non-network $19 $55 $41 $83 $175 per eye $50 for Type 2 & 3 Services $1,500 $1,000 per person per person 100% 80% 50% Network Middle 100% URC*** 80% URC*** 50% URC*** $30 $76 $60 $122 $175 per eye $50 for Type 2 & 3 Services $2,000 $1,500 per person per person 100% 80% 50% Network High Non-Network A current Network of dentists can be found at www.ameritas.com, go to Find a Provider-dental. ** Members are responsible for any balance billing from Non-Network Dentists. ***Non-Network Benefits are paid according to Usual, Reasonable & Customary (URC). Members are responsible for any balance billing from Non-Network Dentists. Type 1 - Diagnostic/Preventative Services: Oral examinations (2 per calendar year) *Routine cleaning (2 per calendar year) *Topical floride up to age 18 *Full mouth or panoramic x-rays (1 in any 3 year period) *Bitewing x-rays (2 per calendar year) *Emergency Palliative treatment to relieve pain *Space maintainers (For premature loss of primary tooth). Type 2 - Basic Services: Restorative amalgams (fillings), restorative composites, denture repair, simple extractions, complex extractions, anesthesia. Type 3 - Major Services: Endodontics – root canal therapy, pulpotomy *Peridontics – treatment of gum disease *Root scaling and root planning *Restorative – Inlay, onlays, crowns (five year waiting period for replacement) *Prosthodontics – full or partial dentures or bridges (five year waiting period for replacement) Benefits are subject to all provisions, terms & conditions of the group contract. Prior authorization recommended for services over $200. *This is only a Summary of Benefits. You will receive a complete list of services with your I.D. card and certificate of insurance. Monthly Premium Employee only Employee + Spouse Employee + Child(ren) Employee + Family $13 $33 $29 $59 $175 per eye Calendar Year Maximum Benefit NEW Lasik Benefits See Schedule See Schedule See Schedule Non-network $50 for Type 2 & 3 Services $1,500 $1,500 per person per person See Schedule See Schedule See Schedule Network Low Annual Deductible Type 1 Coverage* Type 2 Coverage* Type 3 Coverage* MEMBER BENEFITS For HOAMCO/Consolidated Personnel Services, Inc. Dental Plan Benefit Summary* TYPE 1 PROCEDURES Plan 1 BENEFIT PERIOD - Calendar Year For Additional Limitations - See Limitations ROUTINE ORAL EVALUATION D0120 Periodic oral evaluation - established patient. D0145 Oral evaluation for a patient under three years of age and counseling with primary caregiver. D0150 Comprehensive oral evaluation - new or established patient. D0180 Comprehensive periodontal evaluation - new or established patient. Maximum Covered Expense $21.00 $16.00 $33.00 $33.00 COMPREHENSIVE EVALUATION: D0150, D0180 x Coverage is limited to 1 of each of these procedures per 1 provider. x In addition, D0150, D0180 coverage is limited to 2 of any of these procedures per 1 benefit period. x D0120, D0145 also contribute(s) to this limitation. x If frequency met, will be considered at an alternate benefit of a D0120/D0145 and count towards this frequency. ROUTINE EVALUATION: D0120, D0145 x Coverage is limited to 2 of any of these procedures per 1 benefit period. x D0150, D0180 also contribute(s) to this limitation. x Procedure D0120 will be considered for individuals age 3 and over. Procedure D0145 will be considered for individuals age 2 and under. COMPLETE SERIES OR PANORAMIC FILM D0210 Intraoral - complete series (including bitewings). D0330 Panoramic film. $68.00 $55.00 COMPLETE SERIES/PANORAMIC FILMS: D0210, D0330 x Coverage is limited to 1 of any of these procedures per 3 year(s). OTHER XRAYS D0220 Intraoral - periapical first film. D0230 Intraoral - periapical each additional film. D0240 Intraoral - occlusal film. D0250 Extraoral - first film. D0260 Extraoral - each additional film. $12.00 $10.00 $17.00 $22.00 $17.00 PERIAPICAL FILMS: D0220, D0230 x The maximum amount considered for x-ray films taken on one day will be equivalent to an allowance of a D0210. BITEWING FILMS D0270 Bitewing - single film. D0272 Bitewings - two films. D0273 Bitewings - three films. D0274 Bitewings - four films. D0277 Vertical bitewings - 7 to 8 films. $11.00 $19.00 $23.00 $30.00 $45.00 BITEWING FILMS: D0270, D0272, D0273, D0274 x Coverage is limited to 2 of any of these procedures per 1 benefit period. x D0277 also contribute(s) to this limitation. x The maximum amount considered for x-ray films taken on one day will be equivalent to an allowance of a D0210. VERTICAL BITEWING FILM: D0277 x Coverage is limited to 1 of any of these procedures per 3 year(s). x The maximum amount considered for x-ray films taken on one day will be equivalent to an allowance of a D0210. PROPHYLAXIS (CLEANING) AND FLUORIDE D1110 Prophylaxis - adult. D1120 Prophylaxis - child. D1203 Topical application of fluoride - child. D1204 Topical application of fluoride - adult. $45.00 $32.00 $17.00 $17.00 9 TYPE 1 PROCEDURES D1206 Topical fluoride varnish; therapeutic application for moderate to high caries risk patients. Maximum Covered Expense $17.00 FLUORIDE: x x x D1203, D1204, D1206 Coverage is limited to 1 of any of these procedures per 1 benefit period. Benefits are considered for persons age 18 and under. An adult fluoride is considered for individuals age 14 and over. A child fluoride is considered for individuals age 13 and under. PROPHYLAXIS: D1110, D1120 x Coverage is limited to 2 of any of these procedures per 1 benefit period. x D4910 also contribute(s) to this limitation. x An adult prophylaxis (cleaning) is considered for individuals age 14 and over. A child prophylaxis (cleaning) is considered for individuals age 13 and under. Benefits for prophylaxis (cleaning) are not available when performed on the same date as periodontal procedures. SEALANT D1351 Sealant - per tooth. $25.00 SEALANT: D1351 x Coverage is limited to 1 of any of these procedures per 3 year(s). x Benefits are considered for persons age 16 and under. x Benefits are considered on permanent molars only. x Coverage is allowed on the occlusal surface only. SPACE MAINTAINERS D1510 Space maintainer - fixed - unilateral. D1515 Space maintainer - fixed - bilateral. D1520 Space maintainer - removable - unilateral. D1525 Space maintainer - removable - bilateral. D1550 Re-cementation of space maintainer. D1555 Removal of fixed space maintainer. $159.00 $260.00 $249.00 $303.00 $33.00 $45.00 SPACE MAINTAINER: D1510, D1515, D1520, D1525 x Coverage is limited to space maintenance for unerupted teeth, following extraction of primary teeth. Allowances include all adjustments within 6 months of placement date. APPLIANCE THERAPY D8210 Removable appliance therapy. D8220 Fixed appliance therapy. $239.00 $239.00 APPLIANCE THERAPY: D8210, D8220 x Coverage is limited to the correction of thumb-sucking. 10 TYPE 2 PROCEDURES Plan 1 BENEFIT PERIOD - Calendar Year For Additional Limitations - See Limitations LIMITED ORAL EVALUATION D0140 Limited oral evaluation - problem focused. D0170 Re-evaluation - limited, problem focused (established patient; not post-operative visit). Maximum Covered Expense $26.00 $26.00 LIMITED ORAL EVALUATION: D0140, D0170 x Coverage is allowed for accidental injury only. If not due to an accident, will be considered at an alternate benefit of a D0120/D0145 and count towards this frequency. ORAL PATHOLOGY/LABORATORY D0472 Accession of tissue, gross examination, preparation and transmission of written report. D0473 Accession of tissue, gross and microscopic examination, preparation and transmission of written report. D0474 Accession of tissue, gross and microscopic examination, including assessment of surgical margins for presence of disease, preparation and transmission of written report. $32.00 $62.00 $62.00 ORAL PATHOLOGY LABORATORY: D0472, D0473, D0474 x Coverage is limited to 1 of any of these procedures per 12 month(s). x Coverage is limited to 1 examination per biopsy/excision. AMALGAM RESTORATIONS (FILLINGS) D2140 Amalgam - one surface, primary or permanent. D2150 Amalgam - two surfaces, primary or permanent. D2160 Amalgam - three surfaces, primary or permanent. D2161 Amalgam - four or more surfaces, primary or permanent. $45.00 $57.00 $69.00 $83.00 AMALGAM RESTORATIONS: D2140, D2150, D2160, D2161 x Coverage is limited to 1 of any of these procedures per 6 month(s). x D2330, D2331, D2332, D2335, D2391, D2392, D2393, D2394, D9911 also contribute(s) to this limitation. RESIN RESTORATIONS (FILLINGS) D2330 Resin-based composite - one surface, anterior. D2331 Resin-based composite - two surfaces, anterior. D2332 Resin-based composite - three surfaces, anterior. D2335 Resin-based composite - four or more surfaces or involving incisal angle (anterior). D2391 Resin-based composite - one surface, posterior. D2392 Resin-based composite - two surfaces, posterior. D2393 Resin-based composite - three surfaces, posterior. D2394 Resin-based composite - four or more surfaces, posterior. D2410 Gold foil - one surface. D2420 Gold foil - two surfaces. D2430 Gold foil - three surfaces. $55.00 $69.00 $86.00 $95.00 $60.00 $76.00 $95.00 $105.00 $45.00 $57.00 $69.00 COMPOSITE RESTORATIONS: D2330, D2331, D2332, D2335, D2391, D2392, D2393, D2394 x Coverage is limited to 1 of any of these procedures per 6 month(s). x D2140, D2150, D2160, D2161, D9911 also contribute(s) to this limitation. x Porcelain and resin benefits are considered for anterior and bicuspid teeth only. x Coverage is limited to necessary placement resulting from decay or replacement due to existing unserviceable restorations. GOLD FOIL RESTORATIONS: D2410, D2420, D2430 x Gold foils are considered at an alternate benefit of an amalgam/composite restoration. STAINLESS STEEL CROWN (PREFABRICATED CROWN) D2390 Resin-based composite crown, anterior. D2930 Prefabricated stainless steel crown - primary tooth. D2931 Prefabricated stainless steel crown - permanent tooth. D2932 Prefabricated resin crown. D2933 Prefabricated stainless steel crown with resin window. D2934 Prefabricated esthetic coated stainless steel crown - primary tooth. $116.00 $98.00 $104.00 $116.00 $116.00 $116.00 STAINLESS STEEL CROWN: D2390, D2930, D2931, D2932, D2933, D2934 11 TYPE 2 PROCEDURES Maximum Covered Expense x x Replacement is limited to 1 of any of these procedures per 12 month(s). Porcelain and resin benefits are considered for anterior and bicuspid teeth only. RECEMENT D2910 Recement inlay, onlay, or partial coverage restoration. D2915 Recement cast or prefabricated post and core. D2920 Recement crown. D6092 Recement implant/abutment supported crown. D6093 Recement implant/abutment supported fixed partial denture. D6930 Recement fixed partial denture. $36.00 $18.00 $35.00 $35.00 $35.00 $49.00 SEDATIVE FILLING D2940 Sedative filling. $33.00 FULL MOUTH DEBRIDEMENT D4355 Full mouth debridement to enable comprehensive evaluation and diagnosis. $56.00 FULL MOUTH DEBRIDEMENT: D4355 x Coverage is limited to 1 of any of these procedures per 5 year(s). PERIODONTAL MAINTENANCE D4910 Periodontal maintenance. $57.00 PERIODONTAL MAINTENANCE: D4910 x Coverage is limited to 2 of any of these procedures per 1 benefit period. x D1110, D1120 also contribute(s) to this limitation. x Coverage is contingent upon evidence of full mouth active periodontal therapy. Benefits are not available if performed on the same date as any other periodontal procedure. DENTURE REPAIR D5510 Repair broken complete denture base. D5520 Replace missing or broken teeth - complete denture (each tooth). D5610 Repair resin denture base. D5620 Repair cast framework. D5630 Repair or replace broken clasp. D5640 Replace broken teeth - per tooth. $57.00 $47.00 $56.00 $67.00 $70.00 $50.00 DENTURE RELINES D5730 Reline complete maxillary denture (chairside). D5731 Reline complete mandibular denture (chairside). D5740 Reline maxillary partial denture (chairside). D5741 Reline mandibular partial denture (chairside). D5750 Reline complete maxillary denture (laboratory). D5751 Reline complete mandibular denture (laboratory). D5760 Reline maxillary partial denture (laboratory). D5761 Reline mandibular partial denture (laboratory). $105.00 $104.00 $94.00 $95.00 $156.00 $153.00 $156.00 $157.00 DENTURE RELINE: D5730, D5731, D5740, D5741, D5750, D5751, D5760, D5761 x Coverage is limited to service dates more than 6 months after placement date. NON-SURGICAL EXTRACTIONS D7111 Extraction, coronal remnants - deciduous tooth. D7140 Extraction, erupted tooth or exposed root (elevation and/or forceps removal). SURGICAL EXTRACTIONS D7210 Surgical removal of erupted tooth requiring elevation of mucoperiosteal flap and removal of bone and/or section of tooth. D7220 Removal of impacted tooth - soft tissue. D7230 Removal of impacted tooth - partially bony. D7240 Removal of impacted tooth - completely bony. $50.00 $50.00 $97.00 $121.00 $161.00 $188.00 12 TYPE 2 PROCEDURES D7241 D7250 Removal of impacted tooth - completely bony, with unusual surgical complications. Surgical removal of residual tooth roots (cutting procedure). OTHER ORAL SURGERY D7260 Oroantral fistula closure. D7261 Primary closure of a sinus perforation. D7270 Tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth. D7272 Tooth transplantation (includes reimplantation from one site to another and splinting and/or stabilization). D7280 Surgical access of an unerupted tooth. D7282 Mobilization of erupted or malpositioned tooth to aid eruption. D7283 Placement of device to facilitate eruption of impacted tooth. D7310 Alveoloplasty in conjunction with extractions - four or more teeth or tooth spaces, per quadrant. D7311 Alveoplasty in conjunction with extractions - one to three teeth or tooth spaces, per quadrant. D7320 Alveoloplasty not in conjunction with extractions - four or more teeth or tooth spaces, per quadrant. D7321 Alveoplasty not in conjunction with extractions - one to three teeth or tooth spaces, per quadrant. D7340 Vestibuloplasty - ridge extension (secondary epithelialization). D7350 Vestibuloplasty - ridge extension (including soft tissue grafts, muscle reattachment, revision of soft tissue attachment and management of hypertrophied and hyperplastic tissue). D7410 Excision of benign lesion up to 1.25 cm. D7411 Excision of benign lesion greater than 1.25 cm. D7412 Excision of benign lesion, complicated. D7413 Excision of malignant lesion up to 1.25 cm. D7414 Excision of malignant lesion greater than 1.25 cm. D7415 Excision of malignant lesion, complicated. D7440 Excision of malignant tumor - lesion diameter up to 1.25 cm. D7441 Excision of malignant tumor - lesion diameter greater than 1.25 cm. D7450 Removal of benign odontogenic cyst or tumor - lesion diameter up to 1.25 cm. D7451 Removal of benign odontogenic cyst or tumor - lesion diameter greater than 1.25 cm. D7460 Removal of benign nonodontogenic cyst or tumor - lesion diameter up to 1.25 cm. D7461 Removal of benign nonodontogenic cyst or tumor - lesion diameter greater than 1.25 cm. D7465 Destruction of lesion(s) by physical or chemical method, by report. D7471 Removal of lateral exostosis (maxilla or mandible). D7472 Removal of torus palatinus. D7473 Removal of torus mandibularis. D7485 Surgical reduction of osseous tuberosity. D7490 Radical resection of maxilla or mandible. D7510 Incision and drainage of abscess - intraoral soft tissue. D7520 Incision and drainage of abscess - extraoral soft tissue. D7530 Removal of foreign body from mucosa, skin, or subcutaneous alveolar tissue. D7540 Removal of reaction producing foreign bodies, musculoskeletal system. D7550 Partial ostectomy/sequestrectomy for removal of non-vital bone. D7560 Maxillary sinusotomy for removal of tooth fragment or foreign body. D7910 Suture of recent small wounds up to 5 cm. D7911 Complicated suture - up to 5 cm. D7912 Complicated suture - greater than 5 cm. D7960 Frenulectomy (frenectomy or frenotomy) - separate procedure. D7963 Frenuloplasty. D7970 Excision of hyperplastic tissue - per arch. D7972 Surgical reduction of fibrous tuberosity. D7980 Sialolithotomy. D7983 Closure of salivary fistula. Maximum Covered Expense $214.00 $101.00 $237.00 $237.00 $143.00 $143.00 $222.00 $160.00 $67.00 $83.00 $42.00 $106.00 $53.00 $153.00 $380.00 $152.00 $194.00 $214.00 $205.00 $150.00 $165.00 $205.00 $150.00 $152.00 $194.00 $152.00 $194.00 $46.00 $135.00 $135.00 $135.00 $220.00 $205.00 $68.00 $78.00 $62.00 $171.00 $171.00 $225.00 $30.00 $34.00 $49.00 $163.00 $203.00 $125.00 $200.00 $188.00 $60.00 REMOVAL OF BONE TISSUE: D7471, D7472, D7473 x Coverage is limited to 5 of any of these procedures per 1 lifetime. 13 TYPE 2 PROCEDURES Maximum Covered Expense BIOPSY OF ORAL TISSUE D7285 Biopsy of oral tissue - hard (bone, tooth). D7286 Biopsy of oral tissue - soft. D7287 Exfoliative cytological sample collection. D7288 Brush biopsy - transepithelial sample collection. $203.00 $110.00 $55.00 $55.00 PALLIATIVE D9110 Palliative (emergency) treatment of dental pain - minor procedure. $38.00 PALLIATIVE TREATMENT: D9110 x Not covered in conjunction with other procedures, except diagnostic x-ray films. ANESTHESIA-GENERAL/IV D9220 Deep sedation/general anesthesia - first 30 minutes. D9221 Deep sedation/general anesthesia - each additional 15 minutes. D9241 Intravenous conscious sedation/analgesia - first 30 minutes. D9242 Intravenous conscious sedation/analgesia - each additional 15 minutes. $144.00 $47.00 $95.00 $23.00 GENERAL ANESTHESIA: D9220, D9221, D9241, D9242 x Coverage is only available with a cutting procedure. Verification of the dentist's anesthesia permit and a copy of the anesthesia report is required. A maximum of two additional units (D9221 or D9242) will be considered. PROFESSIONAL CONSULT/VISIT/SERVICES D9310 Consultation - diagnostic service provided by dentist or physician other than requesting dentist or physician. D9430 Office visit for observation (during regularly scheduled hours) - no other services performed. D9440 Office visit - after regularly scheduled hours. D9930 Treatment of complications (post-surgical) - unusual circumstances, by report. $38.00 $26.00 $47.00 $29.00 CONSULTATION: D9310 x Coverage is limited to 1 of any of these procedures per 1 provider. OFFICE VISIT: D9430, D9440 x Procedure D9430 is allowed for accidental injury only. Procedure D9440 will be allowed on the basis of services rendered or visit, whichever is greater. OCCLUSAL ADJUSTMENT D9951 Occlusal adjustment - limited. D9952 Occlusal adjustment - complete. $36.00 $181.00 OCCLUSAL ADJUSTMENT: D9951, D9952 x Coverage is considered only when performed in conjunction with periodontal procedures for the treatment of periodontal disease. MISCELLANEOUS D0486 Laboratory accession of brush biopsy sample, microscopic examination, preparation and transmission of written report. D2951 Pin retention - per tooth, in addition to restoration. D9911 Application of desensitizing resin for cervical and/or root surfaces, per tooth. $32.00 $17.00 $55.00 DESENSITIZATION: D9911 x Coverage is limited to 1 of any of these procedures per 6 month(s). x D2140, D2150, D2160, D2161, D2330, D2331, D2332, D2335, D2391, D2392, D2393, D2394 also contribute(s) to this limitation. x Porcelain and resin benefits are considered for anterior and bicuspid teeth only. x Coverage is limited to necessary placement resulting from decay or replacement due to existing unserviceable restorations. 14 TYPE 3 PROCEDURES Plan 1 BENEFIT PERIOD - Calendar Year For Additional Limitations - See Limitations INLAY RESTORATIONS D2510 Inlay - metallic - one surface. D2520 Inlay - metallic - two surfaces. D2530 Inlay - metallic - three or more surfaces. D2610 Inlay - porcelain/ceramic - one surface. D2620 Inlay - porcelain/ceramic - two surfaces. D2630 Inlay - porcelain/ceramic - three or more surfaces. D2650 Inlay - resin-based composite - one surface. D2651 Inlay - resin-based composite - two surfaces. D2652 Inlay - resin-based composite - three or more surfaces. Maximum Covered Expense $172.00 $205.00 $221.00 $190.00 $207.00 $226.00 $197.00 $195.00 $201.00 INLAY: D2510, D2520, D2530, D2610, D2620, D2630, D2650, D2651, D2652 x Inlays will be considered at an alternate benefit of an amalgam/composite restoration and only when resulting from caries (tooth decay) or traumatic injury. ONLAY RESTORATIONS D2542 Onlay - metallic - two surfaces. D2543 Onlay - metallic - three surfaces. D2544 Onlay - metallic - four or more surfaces. D2642 Onlay - porcelain/ceramic - two surfaces. D2643 Onlay - porcelain/ceramic - three surfaces. D2644 Onlay - porcelain/ceramic - four or more surfaces. D2662 Onlay - resin-based composite - two surfaces. D2663 Onlay - resin-based composite - three surfaces. D2664 Onlay - resin-based composite - four or more surfaces. $223.00 $249.00 $259.00 $223.00 $250.00 $258.00 $210.00 $216.00 $229.00 ONLAY: D2542, D2543, D2544, D2642, D2643, D2644, D2662, D2663, D2664 x Replacement is limited to 1 of any of these procedures per 5 year(s). x D2510, D2520, D2530, D2610, D2620, D2630, D2650, D2651, D2652, D2710, D2712, D2720, D2721, D2722, D2740, D2750, D2751, D2752, D2780, D2781, D2782, D2783, D2790, D2791, D2792, D2794, D6600, D6601, D6602, D6603, D6604, D6605, D6606, D6607, D6608, D6609, D6610, D6611, D6612, D6613, D6614, D6615, D6624, D6634, D6710, D6720, D6721, D6722, D6740, D6750, D6751, D6752, D6780, D6781, D6782, D6783, D6790, D6791, D6792, D6794 also contribute(s) to this limitation. x Frequency is waived for accidental injury. x Porcelain and resin benefits are considered for anterior and bicuspid teeth only. x Coverage is limited to necessary placement resulting from caries (tooth decay) or traumatic injury. x Benefits will not be considered if procedure D2390, D2930, D2931, D2932, D2933 or D2934 has been performed within 12 months. CROWNS SINGLE RESTORATIONS D2710 Crown - resin-based composite (indirect). D2712 Crown - 3/4 resin-based composite (indirect). D2720 Crown - resin with high noble metal. D2721 Crown - resin with predominantly base metal. D2722 Crown - resin with noble metal. D2740 Crown - porcelain/ceramic substrate. D2750 Crown - porcelain fused to high noble metal. D2751 Crown - porcelain fused to predominantly base metal. D2752 Crown - porcelain fused to noble metal. D2780 Crown - 3/4 cast high noble metal. D2781 Crown - 3/4 cast predominantly base metal. D2782 Crown - 3/4 cast noble metal. D2783 Crown - 3/4 porcelain/ceramic. $98.00 $242.00 $249.00 $190.00 $233.00 $269.00 $261.00 $224.00 $240.00 $249.00 $216.00 $226.00 $269.00 15 TYPE 3 PROCEDURES D2790 D2791 D2792 D2794 Crown - full cast high noble metal. Crown - full cast predominantly base metal. Crown - full cast noble metal. Crown - titanium. Maximum Covered Expense $249.00 $216.00 $226.00 $249.00 CROWN: D2710, D2712, D2720, D2721, D2722, D2740, D2750, D2751, D2752, D2780, D2781, D2782, D2783, D2790, D2791, D2792, D2794 x Replacement is limited to 1 of any of these procedures per 5 year(s). x D2510, D2520, D2530, D2542, D2543, D2544, D2610, D2620, D2630, D2642, D2643, D2644, D2650, D2651, D2652, D2662, D2663, D2664, D6600, D6601, D6602, D6603, D6604, D6605, D6606, D6607, D6608, D6609, D6610, D6611, D6612, D6613, D6614, D6615, D6624, D6634, D6710, D6720, D6721, D6722, D6740, D6750, D6751, D6752, D6780, D6781, D6782, D6783, D6790, D6791, D6792, D6794 also contribute(s) to this limitation. x Frequency is waived for accidental injury. x Porcelain and resin benefits are considered for anterior and bicuspid teeth only. x Procedures that contain titanium or high noble metal will be considered at the corresponding noble metal allowance. x Coverage is limited to necessary placement resulting from caries (tooth decay) or traumatic injury. x Benefits will not be considered if procedure D2390, D2930, D2931, D2932, D2933 or D2934 has been performed within 12 months. CORE BUILD-UP D2950 Core buildup, including any pins. D6973 Core build up for retainer, including any pins. $54.00 $54.00 POST AND CORE D2952 Post and core in addition to crown, indirectly fabricated. D2954 Prefabricated post and core in addition to crown. $86.00 $72.00 FIXED CROWN AND PARTIAL DENTURE REPAIR D2980 Crown repair, by report. D6980 Fixed partial denture repair, by report. D9120 Fixed partial denture sectioning. $44.00 $49.00 $49.00 ENDODONTICS MISCELLANEOUS D3220 Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction and application of medicament. D3221 Pulpal debridement, primary and permanent teeth. D3222 Partial Pulpotomy for apexogenesis - permanent tooth with incomplete root development. D3230 Pulpal therapy (resorbable filling) - anterior, primary tooth (excluding final restoration). D3240 Pulpal therapy (resorbable filling) - posterior, primary tooth (excluding final restoration). D3333 Internal root repair of perforation defects. D3351 Apexification/recalcification - initial visit (apical closure/calcific repair of perforations, root resorption, etc.) D3352 Apexication/recalcification - interim medication replacement (apical closure/calcific repair of perforations, root resorption, etc.). D3353 Apexification/recalcification - final visit (includes completed root canal therapy - apical closure/calcific repair of perforations, root resorption, etc.). D3430 Retrograde filling - per root. D3450 Root amputation - per root. D3920 Hemisection (including any root removal), not including root canal therapy. $34.00 $34.00 $52.00 $46.00 $40.00 $56.00 $56.00 $38.00 $111.00 $44.00 $104.00 $88.00 ENDODONTICS MISCELLANEOUS: D3333, D3430, D3450, D3920 x Procedure D3333 is limited to permanent teeth only. ENDODONTIC THERAPY (ROOT CANALS) D3310 Endodontic therapy, anterior tooth. D3320 Endodontic therapy, bicuspid tooth. D3330 Endodontic therapy, molar. D3332 Incomplete endodontic therapy; inoperable, unrestorable or fractured tooth. D3346 Retreatment of previous root canal therapy - anterior. $156.00 $184.00 $241.00 $92.00 $195.00 16 TYPE 3 PROCEDURES D3347 D3348 Retreatment of previous root canal therapy - bicuspid. Retreatment of previous root canal therapy - molar. Maximum Covered Expense $224.00 $278.00 ROOT CANALS: D3310, D3320, D3330, D3332 x Benefits are considered on permanent teeth only. x Allowances include intraoperative films and cultures but exclude final restoration. RETREATMENT OF ROOT CANAL: D3346, D3347, D3348 x Coverage is limited to 1 of any of these procedures per 12 month(s). x D3310, D3320, D3330 also contribute(s) to this limitation. x Benefits are considered on permanent teeth only. x Coverage is limited to service dates more than 12 months after root canal therapy. Allowances include intraoperative films and cultures but exclude final restoration. SURGICAL ENDODONTICS D3410 Apicoectomy/periradicular surgery - anterior. D3421 Apicoectomy/periradicular surgery - bicuspid (first root). D3425 Apicoectomy/periradicular surgery - molar (first root). D3426 Apicoectomy/periradicular surgery (each additional root). SURGICAL PERIODONTICS D4210 Gingivectomy or gingivoplasty - four or more contiguous teeth or tooth bounded spaces per quadrant. D4211 Gingivectomy or gingivoplasty - one to three contiguous teeth or tooth bounded spaces per quadrant. D4240 Gingival flap procedure, including root planing - four or more contiguous teeth or tooth bounded spaces per quadrant. D4241 Gingival flap procedure, including root planing - one to three contiguous teeth or tooth bounded spaces per quadrant. D4260 Osseous surgery (including flap entry and closure) - four or more contiguous teeth or tooth bounded spaces per quadrant. D4261 Osseous surgery (including flap entry and closure) - one to three contiguous teeth or tooth bounded spaces per quadrant. D4263 Bone replacement graft - first site in quadrant. D4264 Bone replacement graft - each additional site in quadrant. D4265 Biologic materials to aid in soft and osseous tissue regeneration. D4270 Pedicle soft tissue graft procedure. D4271 Free soft tissue graft procedure (including donor site surgery). D4273 Subepithelial connective tissue graft procedures, per tooth. D4274 Distal or proximal wedge procedure (when not performed in conjunction with surgical procedures in the same anatomical area). D4275 Soft tissue allograft. D4276 Combined connective tissue and double pedicle graft, per tooth. $161.00 $185.00 $201.00 $72.00 $102.00 $51.00 $140.00 $70.00 $256.00 $128.00 $84.00 $63.00 $42.00 $189.00 $200.00 $233.00 $112.00 $200.00 $233.00 BONE GRAFTS: D4263, D4264, D4265 x Each quadrant is limited to 1 of each of these procedures per 3 year(s). x Coverage is limited to treatment of periodontal disease. GINGIVECTOMY: D4210, D4211 x Each quadrant is limited to 1 of each of these procedures per 3 year(s). x Coverage is limited to treatment of periodontal disease. OSSEOUS SURGERY: D4240, D4241, D4260, D4261 x Each quadrant is limited to 1 of each of these procedures per 3 year(s). x Coverage is limited to treatment of periodontal disease. TISSUE GRAFTS: D4270, D4271, D4273, D4275, D4276 x Each quadrant is limited to 2 of any of these procedures per 3 year(s). x Coverage is limited to treatment of periodontal disease. CROWN LENGTHENING D4249 Clinical crown lengthening - hard tissue. $154.00 NON-SURGICAL PERIODONTICS D4341 Periodontal scaling and root planing - four or more teeth per quadrant. D4342 Periodontal scaling and root planing - one to three teeth, per quadrant. $52.00 $26.00 17 TYPE 3 PROCEDURES D4381 Localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth, by report. Maximum Covered Expense $38.00 CHEMOTHERAPEUTIC AGENTS: D4381 x Each quadrant is limited to 2 of any of these procedures per 2 year(s). PERIODONTAL SCALING & ROOT PLANING: D4341, D4342 x Each quadrant is limited to 1 of each of these procedures per 2 year(s). PROSTHODONTICS - FIXED/REMOVABLE (DENTURES) D5110 Complete denture - maxillary. D5120 Complete denture - mandibular. D5130 Immediate denture - maxillary. D5140 Immediate denture - mandibular. D5211 Maxillary partial denture - resin base (including any conventional clasps, rests and teeth). D5212 Mandibular partial denture - resin base (including any conventional clasps, rests and teeth). D5213 Maxillary partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth). D5214 Mandibular partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth). D5225 Maxillary partial denture - flexible base (including any clasps, rests and teeth). D5226 Mandibular partial denture - flexible base (including any clasps, rests and teeth). D5281 Removable unilateral partial denture - one piece cast metal (including clasps and teeth). D5670 Replace all teeth and acrylic on cast metal framework (maxillary). D5671 Replace all teeth and acrylic on cast metal framework (mandibular). D5810 Interim complete denture (maxillary). D5811 Interim complete denture (mandibular). D5820 Interim partial denture (maxillary). D5821 Interim partial denture (mandibular). D5860 Overdenture - complete, by report. D5861 Overdenture - partial, by report. D6053 Implant/abutment supported removable denture for completely edentulous arch. D6054 Implant/abutment supported removable denture for partially edentulous arch. D6078 Implant/abutment supported fixed denture for completely edentulous arch. D6079 Implant/abutment supported fixed denture for partially edentulous arch. $278.00 $270.00 $302.00 $292.00 $200.00 $232.00 $323.00 $323.00 $200.00 $232.00 $173.00 $200.00 $232.00 $123.00 $130.00 $108.00 $114.00 $278.00 $323.00 $278.00 $323.00 $278.00 $323.00 COMPLETE DENTURE: D5110, D5120, D5130, D5140, D5860, D6053, D6078 x Replacement is limited to 1 of any of these procedures per 5 year(s). x Frequency is waived for accidental injury. x Allowances include adjustments within 6 months after placement date. Procedures D5860, D6053, and D6078 are considered at an alternate benefit of a D5110/D5120. PARTIAL DENTURE: D5211, D5212, D5213, D5214, D5225, D5226, D5281, D5670, D5671, D5861, D6054, D6079 x Replacement is limited to 1 of any of these procedures per 5 year(s). x Frequency is waived for accidental injury. x Allowances include adjustments within 6 months of placement date. Procedures D5861, D6054, and D6079 are considered at an alternate benefit of a D5213/D5214. DENTURE ADJUSTMENTS D5410 Adjust complete denture - maxillary. D5411 Adjust complete denture - mandibular. D5421 Adjust partial denture - maxillary. D5422 Adjust partial denture - mandibular. $16.00 $15.00 $16.00 $16.00 DENTURE ADJUSTMENT: D5410, D5411, D5421, D5422 x Coverage is limited to dates of service more than 6 months after placement date. ADD TOOTH/CLASP TO EXISTING PARTIAL D5650 Add tooth to existing partial denture. D5660 Add clasp to existing partial denture. $36.00 $42.00 DENTURE REBASES D5710 Rebase complete maxillary denture. $101.00 18 TYPE 3 PROCEDURES D5711 D5720 D5721 Rebase complete mandibular denture. Rebase maxillary partial denture. Rebase mandibular partial denture. TISSUE CONDITIONING D5850 Tissue conditioning, maxillary. D5851 Tissue conditioning, mandibular. PROSTHODONTICS - FIXED D6058 Abutment supported porcelain/ceramic crown. D6059 Abutment supported porcelain fused to metal crown (high noble metal). D6060 Abutment supported porcelain fused to metal crown (predominantly base metal). D6061 Abutment supported porcelain fused to metal crown (noble metal). D6062 Abutment supported cast metal crown (high noble metal). D6063 Abutment supported cast metal crown (predominantly base metal). D6064 Abutment supported cast metal crown (noble metal). D6065 Implant supported porcelain/ceramic crown. D6066 Implant supported porcelain fused to metal crown (titanium, titanium alloy, high noble metal). D6067 Implant supported metal crown (titanium, titanium alloy, high noble metal). D6068 Abutment supported retainer for porcelain/ceramic FPD. D6069 Abutment supported retainer for porcelain fused to metal FPD (high noble metal). D6070 Abutment supported retainer for porcelain fused to metal FPD (predominantly base metal). D6071 Abutment supported retainer for porcelain fused to metal FPD (noble metal). D6072 Abutment supported retainer for cast metal FPD (high noble metal). D6073 Abutment supported retainer for cast metal FPD (predominantly base metal). D6074 Abutment supported retainer for cast metal FPD (noble metal). D6075 Implant supported retainer for ceramic FPD. D6076 Implant supported retainer for porcelain fused to metal FPD (titanium, titanium alloy, or high noble metal). D6077 Implant supported retainer for cast metal FPD (titanium, titanium alloy or high noble metal). D6094 Abutment supported crown - (titanium). D6194 Abutment supported retainer crown for FPD - (titanium). D6205 Pontic - indirect resin based composite. D6210 Pontic - cast high noble metal. D6211 Pontic - cast predominantly base metal. D6212 Pontic - cast noble metal. D6214 Pontic - titanium. D6240 Pontic - porcelain fused to high noble metal. D6241 Pontic - porcelain fused to predominantly base metal. D6242 Pontic - porcelain fused to noble metal. D6245 Pontic - porcelain/ceramic. D6250 Pontic - resin with high noble metal. D6251 Pontic - resin with predominantly base metal. D6252 Pontic - resin with noble metal. D6545 Retainer - cast metal for resin bonded fixed prosthesis. D6548 Retainer - porcelain/ceramic for resin bonded fixed prosthesis. D6600 Inlay - porcelain/ceramic, two surfaces. D6601 Inlay - porcelain/ceramic, three or more surfaces. D6602 Inlay - cast high noble metal, two surfaces. D6603 Inlay - cast high noble metal, three or more surfaces. D6604 Inlay - cast predominantly base metal, two surfaces. D6605 Inlay - cast predominantly base metal, three or more surfaces. D6606 Inlay - cast noble metal, two surfaces. D6607 Inlay - cast noble metal, three or more surfaces. Maximum Covered Expense $107.00 $97.00 $102.00 $28.00 $30.00 $232.00 $253.00 $253.00 $232.00 $253.00 $253.00 $275.00 $232.00 $253.00 $253.00 $232.00 $253.00 $253.00 $232.00 $253.00 $253.00 $275.00 $232.00 $253.00 $253.00 $253.00 $253.00 $209.00 $253.00 $253.00 $275.00 $253.00 $253.00 $253.00 $232.00 $232.00 $253.00 $232.00 $275.00 $84.00 $84.00 $207.00 $227.00 $186.00 $204.00 $161.00 $177.00 $169.00 $186.00 19 TYPE 3 PROCEDURES D6608 D6609 D6610 D6611 D6612 D6613 D6614 D6615 D6624 D6634 D6710 D6720 D6721 D6722 D6740 D6750 D6751 D6752 D6780 D6781 D6782 D6783 D6790 D6791 D6792 D6794 D6940 Onlay - porcelain/ceramic, two surfaces. Onlay - porcelain/ceramic, three or more surfaces. Onlay - cast high noble metal, two surfaces. Onlay - cast high noble metal, three or more surfaces. Onlay - cast predominantly base metal, two surfaces. Onlay - cast predominantly base metal, three or more surfaces. Onlay - cast noble metal, two surfaces. Onlay - cast noble metal, three or more surfaces. Inlay - titanium. Onlay - titanium. Crown - indirect resin based composite. Crown - resin with high noble metal. Crown - resin with predominantly base metal. Crown - resin with noble metal. Crown - porcelain/ceramic. Crown - porcelain fused to high noble metal. Crown - porcelain fused to predominantly base metal. Crown - porcelain fused to noble metal. Crown - 3/4 cast high noble metal. Crown - 3/4 cast predominantly base metal. Crown - 3/4 cast noble metal. Crown - 3/4 porcelain/ceramic. Crown - full cast high noble metal. Crown - full cast predominantly base metal. Crown - full cast noble metal. Crown - titanium. Stress breaker. Maximum Covered Expense $223.00 $246.00 $204.00 $225.00 $177.00 $194.00 $186.00 $204.00 $204.00 $225.00 $209.00 $253.00 $131.00 $211.00 $232.00 $275.00 $253.00 $232.00 $275.00 $253.00 $232.00 $232.00 $253.00 $253.00 $232.00 $253.00 $70.00 FIXED PARTIAL CROWN: D6710, D6720, D6721, D6722, D6740, D6750, D6751, D6752, D6780, D6781, D6782, D6783, D6790, D6791, D6792, D6794 x Replacement is limited to 1 of any of these procedures per 5 year(s). x D2510, D2520, D2530, D2542, D2543, D2544, D2610, D2620, D2630, D2642, D2643, D2644, D2650, D2651, D2652, D2662, D2663, D2664, D2710, D2712, D2720, D2721, D2722, D2740, D2750, D2751, D2752, D2780, D2781, D2782, D2783, D2790, D2791, D2792, D2794, D6600, D6601, D6602, D6603, D6604, D6605, D6606, D6607, D6608, D6609, D6610, D6611, D6612, D6613, D6614, D6615, D6624, D6634 also contribute(s) to this limitation. x Frequency is waived for accidental injury. x Porcelain and resin benefits are considered for anterior and bicuspid teeth only. x Procedures that contain titanium or high noble metal will be considered at the corresponding noble metal allowance. x Benefits will not be considered if procedure D2390, D2930, D2931, D2932, D2933 or D2934 has been performed within 12 months. FIXED PARTIAL INLAY: D6600, D6601, D6602, D6603, D6604, D6605, D6606, D6607, D6624 x Replacement is limited to 1 of any of these procedures per 5 year(s). x D2510, D2520, D2530, D2542, D2543, D2544, D2610, D2620, D2630, D2642, D2643, D2644, D2650, D2651, D2652, D2662, D2663, D2664, D2710, D2712, D2720, D2721, D2722, D2740, D2750, D2751, D2752, D2780, D2781, D2782, D2783, D2790, D2791, D2792, D2794, D6608, D6609, D6610, D6611, D6612, D6613, D6614, D6615, D6634, D6710, D6720, D6721, D6722, D6740, D6750, D6751, D6752, D6780, D6781, D6782, D6783, D6790, D6791, D6792, D6794 also contribute(s) to this limitation. x Frequency is waived for accidental injury. x Porcelain and resin benefits are considered for anterior and bicuspid teeth only. x Procedures that contain titanium or high noble metal will be considered at the corresponding noble metal allowance. x Benefits will not be considered if procedure D2390, D2930, D2931, D2932, D2933 or D2934 has been performed within 12 months. FIXED PARTIAL ONLAY: D6608, D6609, D6610, D6611, D6612, D6613, D6614, D6615, D6634 x Replacement is limited to 1 of any of these procedures per 5 year(s). x D2510, D2520, D2530, D2542, D2543, D2544, D2610, D2620, D2630, D2642, D2643, D2644, D2650, D2651, D2652, D2662, D2663, D2664, D2710, D2712, D2720, D2721, D2722, D2740, D2750, D2751, D2752, D2780, D2781, D2782, D2783, D2790, D2791, D2792, D2794, D6600, D6601, D6602, D6603, D6604, D6605, D6606, D6607, D6624, D6710, D6720, D6721, D6722, D6740, D6750, D6751, D6752, D6780, D6781, D6782, D6783, D6790, D6791, D6792, D6794 also contribute(s) to this limitation. x Frequency is waived for accidental injury. x Porcelain and resin benefits are considered for anterior and bicuspid teeth only. x Procedures that contain titanium or high noble metal will be considered at the corresponding noble metal allowance. 20 TYPE 3 PROCEDURES Maximum Covered Expense x Benefits will not be considered if procedure D2390, D2930, D2931, D2932, D2933 or D2934 has been performed within 12 months. FIXED PARTIAL PONTIC: D6205, D6210, D6211, D6212, D6214, D6240, D6241, D6242, D6245, D6250, D6251, D6252 x Replacement is limited to 1 of any of these procedures per 5 year(s). x D5211, D5212, D5213, D5214, D5225, D5226, D5281, D6058, D6059, D6060, D6061, D6062, D6063, D6064, D6065, D6066, D6067, D6068, D6069, D6070, D6071, D6072, D6073, D6074, D6075, D6076, D6077, D6094, D6194 also contribute(s) to this limitation. x Frequency is waived for accidental injury. x Porcelain and resin benefits are considered for anterior and bicuspid teeth only. x Procedures that contain titanium or high noble metal will be considered at the corresponding noble metal allowance. IMPLANT SUPPORTED CROWN: D6058, D6059, D6060, D6061, D6062, D6063, D6064, D6065, D6066, D6067, D6094 x Replacement is limited to 1 of any of these procedures per 5 year(s). x D5211, D5212, D5213, D5214, D5225, D5226, D5281, D6194, D6205, D6210, D6211, D6212, D6214, D6240, D6241, D6242, D6245, D6250, D6251, D6252 also contribute(s) to this limitation. x Frequency is waived for accidental injury. x Porcelain and resin benefits are considered for anterior and bicuspid teeth only. x Procedures that contain titanium or high noble metal will be considered at the corresponding noble metal allowance. IMPLANT SUPPORTED RETAINER: D6068, D6069, D6070, D6071, D6072, D6073, D6074, D6075, D6076, D6077, D6194 x Replacement is limited to 1 of any of these procedures per 5 year(s). x D5211, D5212, D5213, D5214, D5225, D5226, D5281, D6058, D6059, D6060, D6061, D6062, D6063, D6064, D6065, D6066, D6067, D6094, D6205, D6210, D6211, D6212, D6214, D6240, D6241, D6242, D6245, D6250, D6251, D6252 also contribute(s) to this limitation. x Frequency is waived for accidental injury. x Porcelain and resin benefits are considered for anterior and bicuspid teeth only. x Procedures that contain titanium or high noble metal will be considered at the corresponding noble metal allowance. CAST POST AND CORE FOR PARTIALS D6970 Post and core in addition to fixed partial denture retainer, indirectly fabricated. D6972 Prefabricated post and core in addition to fixed partial denture retainer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¶VRIIHUGLVFRXQWVRQLWHPVSXUFKDVHG DIWHUWKHLQVXUDQFHEHQHILWKDVEHHQXVHG 6HUYLFH $OO2WKHU3DUWLFLSDWLQJ3URYLGHUV 2XWRI1HWZRUN ([DPSHU\HDU FRSD\ 8SWR 0DWHULDOV FRSD\ 6WG3ODVWLF/HQVHVSHU\HDU 6LQJOH9LVLRQ %LIRFDO 7ULIRFDO /HQWLFXODU 3URJUHVVLYH &RYHUHG &RYHUHG &RYHUHG DOORZDQFH DOORZDQFH 8SWR 8SWR 8SWR 8SWR 8SWR )UDPHVSHU\HDU 0HPEHUPD\VHOHFWDQ\IUDPH DYDLODEOH UHWDLOIUDPHDOORZDQFH &RYHUVDZLGHVHOHFWLRQRIIUDPHV UHWDLOIUDPHDW:DO0DUW6DP¶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¶&RPSHQVDWLRQRUVLPLODU ODZRUZKLFKLVZRUNUHODWHG 3ODLQRUSUHVFULSWLRQVXQJODVVHVRUWLQWHGOHQVHV 6XEQRUPDOYLVLRQDLGV &KDUJHVLQH[FHVVRI8VXDODQG&XVWRPDU\IRUVHUYLFHVDQG PDWHULDOV ([SHULPHQWDORUQRQFRQYHQWLRQDOWUHDWPHQWVRUGHYLFHV 6DIHW\H\HZHDU 6SHFWDFOHOHQVVW\OHVPDWHULDOVWUHDWPHQWVRU³DGGRQV´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lwaysCare Employee Benefits Underwritten by National Guardian Life Insurance Company Administered by: Starmount Financial Corporation PO Box 98100 Baton Rouge, LA 70898-9100 Fax Completed Form to (602) 230-8969 Vision Insurance Enrollment Form Please print and complete all sections. See instructions below. EMPLOYEE INFORMATION Employer Name Group Number Consolidated Personnel Services, Inc. Location 2CPS908 Last Name (Employee / Subscriber) First Name A Sex T M C F Home Street Address City/State/Zip A T C A T C A T C A T C A T C A T C Sex M F Sex M F Sex M F Sex M F Sex M F Sex M F M.I. Date of Birth Home Phone ( FAMILY INFORMATION A=ADD T=TERMINATE C=CHANGE Date of Hire Effective Date * ) (CHILDREN COVERED UP TO AGE 26) M.I. - Social Security Number Work Phone ( Last Name (Spouse) First Name Last Name (Dependent) First Name M.I. Date of Birth Last Name (Dependent) First Name M.I. Date of Birth Last Name (Dependent) First Name M.I. Date of Birth Last Name (Dependent) First Name M.I. Date of Birth Last Name (Dependent) First Name M.I. Date of Birth ) - Date of Birth Do you or any of your dependents have other vision insurance? Yes No If yes, please give: Policyholder ____________________________ and Insurance Company ___________________________________________ I elect the following vision coverage: Coverage Employee Only Employee & Spouse Employee & Child(ren) Employee & Family Cost $6.00 $12.00 $10.00 $16.00 Waived Enrollment in this plan is binding under Section 125 of the Internal Revenue Service Code, which makes it possible for employers to offer their employees a choice of non-taxable benefits. After a participant has elected and begun to receive benefits under the plan, the plan may not allow the participant to revoke or make changes to the benefit election unless one of the following rules apply: Under the Health Insurance Portability & Accountability Act of 1996 (HIPAA), group health plans are required to permit eligible employees to enroll for coverage following the loss of other health coverage or if a person becomes an eligible spouse or dependent of an eligible employee through birth, marriage, adoption, or placement for adoption. In addition, under the Change in Status rules, a plan may permit participants to revoke or make change to a benefit election if a change in status occurs and the election change is “consistent” with the change in status. Those rules apply to a change in employment status, cases where a dependant satisfies or ceases to satisfy the requirements of eligibility, judgment, decree or order and entitlement to Medicare or Medicaid. Employee Signature: ____________________________________________ Date: __________________________ Acceptance or declination of coverage must be confirmed by employee’s signature above. NOTE: Coverage for a Late Entrant or Re-enrollee will be limited to the Vision Examination benefit in the Benefits Summary during the first 24 months after the Late Entrant’s or Re-enrollee’s Effective Date. This limited coverage also applies to the Late Entrant’s or Re-enrollee’s Dependents, if enrolled. Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. SYMETRA LIFE INSURANCE SEGURO DE VIDA SYMETRA This program of group term life insurance is being made available to the employees of Consolidated Personnel Services, Inc. through payroll deduction for those employees working a minimum of 20 hours per week. By completing the enclosed enrollment material authorizing Consolidated Personnel Services, Inc. to make payroll deductions, you are eligible for: Group term life insurance for yourself from $10,000.00 to $100,000.00 in increments of $10,000.00. *Coverage reduces 50% at age 70, 70% at age 75 and 80% at age 80. One-half the amount of insurance you have on yourself is available for your spouses’ coverage. Spousal coverage automatically terminates at the age of 70. $5,000.00 of group term life insurance is available on your eligible children. Children are eligible if they are between 14 days and 19 years, 23 years if the child(ren) are still in school.** The monthly premium rates have been specially prepared for Consolidated Personnel Services, Inc. and are based on age: (Spouse rate is based on employee’s age. Child rate is $1 for all children.) Age Bands 15-29 30-39 40-49 50-59 60-69 70-79 per $1,000.00 of insurance $ .12 $ .18 $ .46 $1 .27 $3 .31 $8 .92 ***Note: Premiums are subject to change without notification when you enter into another Age Band. **Child coverage amount may be subject to state restrictions. Child coverage is available only if spouse coverage is chosen as well, unless you are a single parent. *Amounts of insurance above $50,000.00 will be subject to proof of good health. Employees who do not enroll during eligibility must submit proof of good health! Enrollment/Waiver and Beneficiary Dedication are on the reverse side of this page and must be faxed back to Consolidated Personnel Services, Inc. @ 602-230-8969. Please call Benefits @ 602-230-8940 for more information. En espanol, llama Departmente de Beneficios Consolidated Personnel Services, Inc. SYMETRA LIFE ENROLLMENT FORM for Consolidated Personnel Services, Inc. Employee Name: __________________________ Social Security #: _______________ Gender: male or female Date of Birth: __________________________ Annual Salary: $_____________ Date of Employment: _____________________ *Amount can be selected in increments of $10,000 up to $100,000. Enter the amount of insurance in ten thousands. Employees who do not enroll during eligibility must submit proof of good health! Amt. Of Ins. * Employee $___________ Spouse YES ( ) NO ( ) X Rate Cost $________ = $________ If yes, employee cost divided by 2 = $________ Child/ren YES ( ) NO ( ) $5,000.00 of coverage per child; $1covers all of your children* = $________ Total Monthly Cost: $________ Employee’s Beneficiary Designation Name: ______________________________ Relationship: _______________________ Address of Beneficiary: ___________________________________________________ ___________________________________________________ The employee will be named the beneficiary of any coverage elected for a spouse or child unless otherwise indicated. ( ) YES, I do want this insurance and I authorize Consolidated Personnel Services, Inc. to make the deductions from my earnings for the total cost of this insurance. ( ) NO, I do not want this insurance at this time. I understand that If I do not enroll within 31 days, when first eligible, that I will not be able to obtain coverage in the future without submitting satisfactory evidence of insurability. _________________________________________ Employee Signature __________________ Date Fax this page to Consolidated Personnel Services, Inc. @ 602-230-8969 for enrollment. Discount Coupon Codes and Ticket Request Form Big Surf Discount Water Park TicketsBig Surf - Day Pass (AZ) $15.00 x # of tickets = $ Please fill out information below if purchasing Big Surf Tickets: Company Name Employee Name Employee Address Employee Signature for Payroll Deduction Fax completed form to (602) 230-8969 This Section for CPS’ Use Only Ticket Numbers: thru by: Discount Park Ticket Codes Park Name (state) Price Username/Password/ Code Web Address Castles & Coasters (AZ) $22.50 Code: CPS3102 www.castlesncoasters.com/buy-tickets Gilroy Gardens (CA) $27.00 (silver pass only) U: CPS; P: 2016fun https://gilroygardens.org (bottom right of web page, under quick links- click Affiliate Log In) or use the direct web address below: http://shop.accesso.com/clients/cedarfair/affiliate?m=6864&ec=600 Golfland/Sunsplash (AZ/CA) Varies Code: CPS https://tickets.golfland.com/ Get Away Today- Disney Varies N/A www.getawaytoday.com or call 855-GET-AWAY Knott’s Berry Farm (CA) Varies Code: cpspeo85016 https://www.knotts.com (top right enter promo code) Varies Lego Land (CA) Code: 295-Deals http://legoland.com/buytickets Wet-N-Wild (AZ) $31.00 No Code- use link http://tinyurl.com/sunfun16 Register, then enter company name: Wild At Work Varies Consolidated Personnel Services http://www.wildatwork.com *Updated 5/24/2016 Forma para Ordenes de Boletos Boletos de Descuento para Parque de Agua Big Surf Parque de Agua (AZ) $15.00 x # de boletos =$ Porfavor de completer la solicitud debajo para comprar boletos de Big Surf: Nombre de Compania Nombre de Empleado Direccion del Empleado Firma de Empleado para deduccion de Cheque (si compra boletos): Regrese forma complete por fax al (602) 230-8969 This Section for CPS’ Use Only Ticket Numbers: thru by: Codigos para los boletos de parques de Diversiones Nombre del Parque Precio Nombre de usario/Contrasena/ Codigo Web Address Castles & Coasters (AZ) $22.50 Codigo:CPS3102(silver pass only) www.castlesncoasters.com/buy-tickets Gilroy Gardens (CA) $27.00 U: CPS; P: 2016fun https://gilroygardens.org (bottom right of web page, under quick links- click Affiliate Log In) or use the direct web address below: http://shop.accesso.com/clients/cedarfair/affiliate?m=6864&ec=600 Golfland/Sunsplash (AZ/CA) Varies Code: CPS https://tickets.golfland.com/ Get Away Today- Disney Varies N/A www.getawaytoday.com or call 855-GET-AWAY Knott’s Berry Farm (CA) Varies Code: cpspeo85016 https://www.knotts.com (top right enter promo code) Varies Lego Land (CA) Code: 295-Deals http://legoland.com/buytickets Wet-N-Wild (AZ) $31.00 No Code- use link http://tinyurl.com/sunfun16 Register, then enter company name: Wild At Work Varies Consolidated Personnel Services http://www.wildatwork.com IDShield ID Shield Monitorear y Restauración Monitor and Restoration $8.95 Individual $18.95 Familia Combinar ambos planes LegalShield y IDShield ID $25.90 Individual $33.90 Familia LA AFILIACIÓN IDSHIELD INCLUYE: Monitoreo de Privacidad La supervisión de su nombre, número de seguro social, fecha de nacimiento, dirección de correo electrónico (hasta 10), números de licencias de conducir y pasaporte, y los números de identificación médica (hasta 10) le ofrece servicio de protección de identidad global que no deja nada al azar. Monitoreo de Seguridad SSN, tarjetas de crédito (hasta 10) y la cuenta bancaria (hasta 10) el seguimiento, el sexo de búsqueda delincuente, alertas de actividad financiera y de seguimiento de cuenta del crédito trimestral a mantener su seguro desde todos los ángulos. Con el plan familiar, Minor Identity Protection está incluido y proporciona supervisión para un máximo de 8 niños menores de 18 años. Consulta Su plan de protección de identidad incluye 24/7/365 soporte en vivo para emergencias cubiertas, asesoría ilimitada, alertas de identidad, notificaciones de violación de datos y la protección de cartera perdida. Restauración Servicio Completo Servicios integrales de recuperación de la identidad de Kroll con licencia investigadores privados y nuestra $ 5.000.000 garantía de servicio a asegurar que si su identidad es robada, será restaurado a su estado pre-robo. Planes IDShield están disponibles a precios individuales o familiares. Una tarifa familiar cubre el miembro, los miembros de su cónyuge y hasta 8 personas dependientes hasta la edad de 18 años. Complete this form to enroll LegalShield IDShield Combinar Nombre (Nombre, Inicial, Apellido)______________________________________________ Fecha de Cumpleaños ____ /____ /________ Direccion de Casa ____________________________________________________________________________________________________________________ Ciudad _________________________________________________________________________ Estado _______ Código postal ________________________ Número de la Seguridad Social ________ - _____ - _________ Email ___________________________________________________________________ Autorizo las deducciones de nómina para mis cuotas de afiliación (signo)_______________________________________________________________________________________ Lista Nombre, Apellido y fecha de nacimiento del miembro (s) a tratar: 1 _______________________________________________________________________ _____ 2 ____________________________________________________________________________ 3 ____________________________________________________________________________ 4 ____________________________________________________________________________ 5 ____________________________________________________________________________ 6 ____________________________________________________________________________ 12/2015 DESCRIPCIÓN DEL PRODUCTO: http://sites.legalshield.com/individuallegalplan/LS+IDTnp Por favor, escanear y enviar por correo electrónico el formulario completado a [email protected] o fax a 602-230-8969 Combinar planes Combineambos BOTH Plans y IDShield LegalShield & IDShield LegalShield $16.95 Individual $18.95 Familia LA AFILIACIÓN LegalShield INCLUYE: Preocuparse menos. Vive mas. $25.90 Individual $33.90 Familia 3Asesoramiento jurídico personal en cuestión ilimitada 3Asistencia de Auditoría del IRS 3Cartas / llamadas realizadas en su nombre 3Trial Defensa (si nombrado acusado / demandado en una 3Contratos y documentos revisados (hasta 15 páginas) Asistencia 3Residencial Préstamo de documentos 3Abogados preparan su testamento, el testamento vital y Tus Health Power Care Notarial 3Moving Violaciónes de Tráfico (disponible después de 15 días después de enrollment) demanda civil cubierta) 3Uncontested Divorce, Separation, Adoption and/or Name Change Representation (available 90 days after enrollment) 3Divorcio de mutuo acuerdo, la separación, la adopción y / o Nombre Change Representación (disponibles 90 días después de la inscripción) 324/7 acceso de emergencia para situaciones cubiertas Planes legales LegalShield cubren el cónyuge miembros, miembros, nunca se casó hijos dependientes menores de 26 que vive en el hogar; hijos a cargo menores de 18 años para los que el miembro es el tutor legal; nunca se casó, hijos dependientes de hasta 26 años si es estudiante universitario de tiempo completo; y físicamente o mentalmente incapacitado hijos a su cargo. Un tipo de persona está disponible para aquellos afiliados que no están casadas, no tienen una pareja de hecho y no tiene hijos menores de edad o dependientes. No hay prestaciones familiares están disponibles para los miembros del plan individual. Pregúntele a su Asociado Independiente para más detalles. & What? CONSOLIDATED PERSONNEL SERVICES INC is offering AFLAC’s voluntary supplemental health benefits for your consideration at payroll rates. AFLAC plans pay cash directly to you in the event of an injury or illness. Ask yourself - If I were to become sick or disabled, would I be able to meet all of my current financial needs? If the answer is no, or if you’re not sure, you should strongly consider AFLAC. Who is AFLAC? AFLAC, founded in 1955, is the World’s Leading Provider of Voluntary Supplemental Health Benefits. Cash benefits are paid directly to you, to use any way you choose, within 7 to 14 days of receipt and submission of claims. What Does AFLAC Offer? A sampling of our menu of programs for you to choose from includes: Short Term Disability, Accident, Cancer, Hospital Protection, Critical Illness and Life Protector. Each policy offered will be explained in detail to you along with the cash benefits they pay. You select each policy on an individual, voluntary basis. **NEW**GUARANTEED ISSUE SHORT TERM DISABILITY**-Own Occupation, monthly benefit from $700-$6,000. Benefits start on day one for an accident and as soon as seven days for an illness. Includes a Maternity Leave Benefit of 6-8 weeks.**NEW** Example: A broken leg with our Accident plan breaks down as follows: Ambulance Benefit $200, Emergency Room Visit $120, Initial Hospitalization $1,000, One-Day Hospital Stay $250, Crutches $125, Follow-up (6 visits) $210, Physical Therapy (10 visits) $350, Lump Sum Benefit $1,250. That is $3,505 CASH back to YOU!!! Example: If you enroll in a Cancer plan and are diagnosed with any internal cancer (Clarks level 3 or higher), you’ll receive a check for the First Occurrence benefit in the amount of $6,000. Plus benefits for Radiation/ Chemotherapy of $500/$900 per week, Surgical benefits up to $5,000, hospital confinement benefit of $300 per day and on and on. This plan also pays $100 per year for a cancer screening. What Does This Do To My Major Medical Plan? It does absolutely nothing. It does not change anything you currently have in place. Your major medical plan will pay for the doctors and hospitals. And AFLAC will pay YOU directly regardless of other insurance. The money you receive from AFLAC can be applied to any out-of-pocket expenses, co-payment and, deductibles; any money left over is yours. Can I Afford This? The policies are being offered to you at a very affordable payroll rate, thanks to your employer. Your premiums will be deducted through a payroll deduction. For How Long Do I Sign Up? CPS starts or stops benefit deductions the first of the month. Therefore, the minimum obligation is 30 days. However, deductions will continue unless you notify CPS to stop them. And, by the way, if you ever leave the company you can keep your AFLAC policies at the same rate! AFLAC will just bill you at home. Does AFLAC offer any other services? Yes, AFLAC also administers your Flexible Spending Accounts. This allows you to set aside money, on a pre-tax basis, to be used for medical expenses that you incur during the year, or for day care expenses. Open enrollment is December of every year for an effective date of January 1 st. How Can I Learn More and Enroll? Contact the Benefits Department at CPS at 602-230-8940 for details! WHO WILL YOU TURN TO FOR FINANCIAL ASSISTANCE? FOR OVER 47 MILLION PEOPLE WORLDWIDE, THE ANSWER IS AFLAC! & CONSOLIDATED PERSONNEL SERVICES INC. esta ofreciendo beneficios voluntarios de salud por medio de AFLAC a su consideracion de costo de pago. Los planes de AFLAC pagan dinero en efectivo directamente a usted en caso de una lesion o enfermedad. Preguntese a si mismo- Si yo me fuera a enfermar o a deshabilitar, podre estar bien con mis finansas? Si su respuesta es no, o si no esta seguro, deberia de cosiderar a AFLAC. Quien es AFLAC? AFLAC fue fundado en 1955, es el proveedor lider a nivel mundial de Beneficios Suplementarios y Voluntarios de Salud. Los beneficios en efectivo son pagados directamente a usted, para uso de cualquier manera que usted guste, que lo recibira dentro de 7 a 14 dias. Que ofrece AFLAC? Algunos de los ejemplos de los programa incluyen : Incapacidad a Corto Plazo, Accidente, Cancer, Indemnizacion por Hospitalizacion, Enfermedades Criticas y Protector de Vida. Cada poliza ofrecida sera explicada a usted junto con la cantidad de dinero en efectivo que se le pagara a usted. Usted selecciona cada poliza individualmente y voluntariamente. **Nuevo** Incapacidad de Corto Plazo Garantizado** Beneficios mensuales entre $700-$6,000. Los beneficios empiezan el primer dia si sufre un accidente y tan pronto como siete dias por una enfermedad. Incluye Licensia de Maternidad de 6-8 semanas**Nuevo** Ejemplo: Una pierna rota con nuestro plan de Accidente se descompone de la siguiente manera: Beneficios de Ambulancia $200, visita a sala de emergencias $120, Hospitalizacion Inicial $1,000, Hospitalizacion de un dia $250, Muletas $125, visitas de seguimiento (6 visitas) $210, Terapia fisica ( 10 visitas) $350, suma global $1,250. Es un total de $3,505 en effectivo que se le regresa a usted!!!!!!! Ejemplo: Si usted se inscribe a una poliza de Cancer y lo diagnostican con cualquier tipo de Cancer internal( Clarks nivel 3 o mas alto) usted recibira un cheque de $6,000. Mas beneficios adicionales para radiacion /quimoterapia de $500/$900 por semana etc etc. Este plan tambien paga $100 al año para examines de cancer. Afectara mi plan medico? No, no cambia nada que usted tenga actualmente. Su plan pagara por sus doctores y hospitales, y AFLAC le pagara a usted directamente independientemente de su otro seguro medico. El dinero que usted reciba de AFLAC lo puede usar para gastos de su propia necesidad. Lo podre pagar? Las polizas son ofrecidas a usted a un precio muy rasonables, gracias a su empleador. Por cuanto tiempo puedo inscribirme? CPS empieza y detiene las deducciones el 1ero de cada mes. Por lo tanto, la obligacion minima es de 30 dias. Sin embargo las deducciones continuaran si usted no notifica a CPS que las detenga. Y si usted decide dejar su trabajo, usted se puede quedar con su poliza de AFLAC a los mismos precios. AFLAC nomas se encarga de cobrarle a usted. AFLAC ofrece otros servicios? Si, AFLAC tambien administra sus gastos de cuentas flexibles. Esto le permite guarder dinero antes de taxes, para que usted lo use para sus billes medicos que usted tenga entre el año o para servicios de guarderia. Inscribsiones son cada mes de Diciembre para que sean effectivos el 1ero de Enero. Como puedo saber mas informacion y subscribirme? Contacte a Yulonda Michaels de CPS al 602-230-8940 para detalles. A QUIEN ACUDIRA USTED PARA ASISTENCIA FINANCIERA? PARA MAS DE 47 MILLONES DE PERSONAS MUNDIAL MENTE, LA RESPUESTA ES AFLAC!!!!
