Assurant / PPO Indemnity Plan

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Voluntary Dental PPO

Good news about dental benefits
for employees of Cypress-Fairbanks ISD Indemnity Plan

Your Dental Plan

As a valued employee of Cypress-Fairbanks I.S.D, you have the opportunity to enroll in a payroll-deduction dental program.

How the Plan Works

This dental plan provides a variety of benefits and allows you and your family to use any dentist or specialist you choose. Benefits are paid after any applicable deductible has been met, up to the annual maximum. Claim payments may be made to you or your dentist, whichever you prefer, unless benefits have been assigned to the provider. You may find a DHA provider by visiting the Assurant Employee Benefits web site at www.assurantemployeebenefits.com – Select “For Members” – “Find a dentist”
– “Dental Health Alliance”. Or call customer service at 800.442.7742.

Vision Care Program

Your dental plan includes a valuable vision care program. You may have access to coverage and/or discounts on eye exams (including contact lens exams), eyeglasses, and other prescription eyewear.

Plan Features

Freedom to Choose any Dentist, Including Specialists
PPO Options Available1
Fast and Accurate Claims Service
24-Month Rate Guarantee
No Referrals Required

IMPORTANT:

Coverage for eligible employees will begin the first of the month following completion of your eligibility period. You must sign up by the Initial Enrollment Deadline, or forfeit the opportunity until the next plan anniversary date.

1This dental program offers a PPO (Preferred Provider Organization) through Dental Health Alliance (DHA®) that provides a variety of cost saving features. Although you may visit any dentist you choose, you will receive maximum savings if you visit a DHA® provider. The allowable amount for non-participating dentists is based on the usual and customary. Patients are responsible for fees in excess of usual and customary.
Plan frequencies, limitations and waiting periods apply.

The insurance policy or policies described in this document are underwritten by Union Security Insurance Company, a subsidiary of Assurant, Inc. Assurant Employee Benefits, a business unit of Assurant, Inc., markets life, disability and dental benefits plans as well as related products and services. In this document, the terms, "we", "us", "our", and the like, refer to each as applicable.

Savings You Can See

Monthly Payroll Deduction

Employee

$32.70

Employee + 1 Dependent

$69.48

Employee + Family

$98.24

Freedom Advance-PPO

Benefit Maximum: Per Person, Per Policy Year	$1,750

Coinsurance Percentage Per Person:
Type I Dental Services	100%
Type II Dental Services	80%
Type III Dental Services	50%

Deductible:
Per Person, Per Policy Year	$50
Waived for Type I Services	Yes

Orthodontia Benefits:
Type IV Deductible	$0
Type IV Coinsurance	50%
Lifetime Orthodontia Max	$1200
Only for dependent children under age 19

Type I Preventive Dental Services, Including:

•

Oral Evaluations – once in any 6-month period

•

Routine Dental Cleanings – once in any 6-month period
(Frequencies combined with Periodontal Maintenance)

•

Fluoride Treatment – once in any 12-month period
Only for children under age 14

•

Sealants – No more than once per tooth per person, only for permanent molar teeth
Only for children under age 16

•

Space Maintainer
Only for children under age 16
(Includes adjustments within 6 months of installation)

•

Harmful Habit Appliance – once per person
Only for children under age 16
(Not covered if Orthodontic related)

•

Bitewing X-Rays – once in any 12-month period

•

X-Rays:

•

Complete series – once in any 60-month period

•

Panoramic – once in any 60-month period (may also be payable in connection with the removal of impacted teeth)

•

Other X-Rays (See Certificate of Insurance)

Type II Basic Dental Services, Including:

•

New Fillings

•

Replacement Fillings – once in any 24-month period per Filling

•

Simple Extractions, Removal of Exposed Roots, Incision and Drainage

•

Certain Lab Tests, Pain Treatment, Therapeutic Drug Injections

Type III Major Dental Services, Including:

•

Endodontics (includes root canal therapy)

•

Endodontic retreatment (covered after 24 months have passed from initial treatment)

•

Complex Oral Surgery; General Anesthesia and IV Sedation when medically required for such Surgery

•

Minor Gum Disease Treatment: (Minor Periodontics)

•

Provisional Splinting, Occlusal Adjustments – once in any 12-month period

•

Scaling and Root Planing – once in any 24-month period per area

•

Periodontal Maintenance – once in any 6-month period

•

(Frequencies combined with Routine Dental Cleanings)

•

Major Gum Disease Treatment: (Major Periodontics

•

Gingivectomy, Osseous Surgery, other major periodontic procedures – once in any 36-month period per area

•

Initial Placement, Replacement and Maintenance of Inlays, Onlays, Crowns, Fixed Partial Dentures (Bridges), and Partial and Complete Dentures

Type IV Orthodontic Dental Services

Limited Orthodontic Treatment

Comprehensive Orthodontic Treatment

Minor Treatment to control harmful habits

Waiting Periods for
Certain Services

From Your
Effective Date

Repairs, Recementing Fixed Partials
Bridges, Inlays, Onlays or Crowns

None

Accidental non-chewing

None

All Services under Endodontics
(includes root canal therapy)

6 Months

Stainless Steel Plastic Crowns
Only for children under age 16

6 Months

Relines, Rebases Dentures

6 Months

Complex Oral Surgery

12 Months

Minor & Major Periodontics

12 Months

Crowns/Inlays/Onlays/Veneers

24 Months

Dentures (Partial or Complete)

24 Months

Fixed Partial Dentures/Bridges

24 Months

Orthodontia

24 Months

Other Policy Provisions
Benefit Adjustments Benefits will be coordinated with any other dental coverage. Under the Alternative Treatment provision, benefits will be payable for the most economical services or supplies meeting broadly accepted standards of dental care. If the cost of a proposed Dental Treatment Plan exceeds $300, it should be submitted for an estimate of benefits payable.

Eligibility
Full-time employee, spouse and unmarried dependent children less than age 25. Unmarried grandchildren who, for Federal income tax purposes, are your dependents at the time of application will also be included as dependents for insurance coverage.

Late Entrants
If you elect coverage more than 31 days after your Eligibility Date, your Effective Date will be delayed to the next plan Anniversary Date.

This is a brief description only. It is not a Certificate of Coverage.

Limitations & Exclusions

Benefits are not payable for:

Treatment which is not dentally necessary, does not have uniform professional endorsement or is experimental or investigational in nature; treatment of the temporomandibular joint; treatment related to changing or maintaining vertical dimension, altering or restoring occlusion, bite registration or bite analysis; treatment which does not have a reasonably favorable prognosis; treatment provided primarily for cosmetic purposes; replacement of natural teeth missing on the effective date of insurance; orthodontic treatment, unless such insurance is provided under the list of covered dental services.

Treatment not included in the list of covered dental services; treatment started before the date insurance begins; treatment started before any applicable waiting period has been served; treatment completed after insurance ends; athletic mouthguards; replacement of lost or stolen appliances; myofunctional therapy; infection control; oral hygiene instruction; broken appointments; completion of claim forms; exams required by a third party; travel time; transportation costs; professional advice given on the phone.

Treatment received due to war, riot, assault or felony; treatment for a work-related injury; treatment of an intentionally self-inflicted injury; treatment performed outside of the United States, other than emergency dental treatment; treatment provided by the person's employer or a member of the person's immediate family; treatment for which a charge would not have been made in the absence of insurance; treatment for which the insured does not have to pay; treatment that has not been both delivered to and accepted by the insured.

Vision Discount Services

ACCESS PLAN

Your dental plan includes a vision discount plan through Vision Service Plan (VSP). The vision plan includes discounts on exams (including contact lens exams) and the purchase of eyeglasses, sunglasses and other prescription eyewear when provided by VSP doctors. VSP is available for you and everyone covered on your dental plan!

Services Available from a VSP Doctor

Other Valuable Features for You

Eye Exams – 20% discount applied to VSP doctor's usual and customary fees for eye exams(1)
Glasses – 20% discount applied to VSP doctor's usual and customary fees for complete pairs of prescription glasses and spectacle lens options(2)
Contact Lenses – 15% discount on VSP network doctor's contact lens exam fee.
Laser VisionCareSM – VSP has contracted with many of the nation's laser surgery facilities and doctors, offering you a discount off PRK and LASIK surgeries, available through contracted laser centers

Immediate savings when using a VSP doctor
You may use the discounts as often as you wish
No waiting periods
No deductibles
No claim forms to fill out

How to Use VSP

Locate a VSP doctor near you. You may either use our Web-based doctor locator at www.vsp.com, or call VSP at 800.877.7195 to request a doctor listing.

Identify yourself as a VSP member and be prepared to provide the enrolled member's social security number when you make your appointment. (The VSP doctor will verify your eligibility and vision plan coverage, and will obtain authorization for services and materials. If you are not currently eligible for services, the VSP doctor is responsible for communicating this to you.)

Your fees are automatically reduced at the time of service
– with no claim forms to fill out!

THIS VISION DISCOUNT PLAN IS NOT INSURANCE.
(1) Note: Does not apply to contact lens services. See contact lens section for applicable discount.
(2) Discounts only offered through the VSP doctor who provided an eye exam
within the last 12 months.

VSP Member Services Support: 800.877.7195
Visit our Web site at www.vsp.com