Hello Readers,
My name is Timothy D Blanchett. I am an Enrollment Specialist with ASI (Affordable Services Inc.). I would like to take a moment to welcome all of you to this blog. I am creating this blog to give all of you the information you need to make an informed decision. My goal is to build a lasting relationship with all of my Customers and earn your trust by providing you with a great service. I feel I can do this by offering you the Nations #1 Health Care Savings Plan and unmatched one on one attention from me personally. I am always available to my customers as I feel the customer always comes first. You the Customer are always right at ASI. We value our Customers because with out you we don’t have a business. We truly believe in what we offer and support our services 100% of the time. Please feel free to read through all of the information available on this blog. You may print it out and show it around to anyone that may be in need of our services. Here at ASI we do not advertise. We feel word of mouth says much more for our Company and how our Customers feel about us as well.
If you are interested in Enrolling with any of our services please contact me. I can be reached via:
Office Phone: (406)-695-2225
Cell Phone: (406)-650-8729
Email: littlemartha@nemontel.net
PS
I am looking forward to working with you very soon.
PPS
For any Medication Price please call me. This site will not allow me to put that much text on one post. I will be glad to compare your medication prices with you to find the very best savings.
Thursday, February 22, 2007
ASI Premier Health Care Plan Details
Hello Readers,
Below is a complete description of the Premier Health Care Plan. Please feel free to contact me with any questions you may have at:
Office Phone 406-695-2225
Cell Phone: 406-650-8729
Email: littlemartha@nemontel.net
$2,000.00 Accident Protection with only a $100 Deductible
You can go to any hospital emergency room or doctor 24 hours a day, 7 days a week with no limit to the number of accidents For claims or information,
If a person is injured by one of the types of accidents described in Schedule A, which happens while covered for this Benefit, then this Benefit will be
paid for the services listed below, which are needed as a direct result of the injury, and from no other cause, within a year of the accident:
a) stays in a hospital
b) medical or surgical treatment by a doctor
c) the services of licensed or graduate nurses
d) x-ray examinations
e) Professional ambulance service from the scene of the accident to the nearest hospital.
The treatment must begin not more than 60 days after the accident.
The amount of this Benefit will be the actual cost of these services, minus the deductible amount shown on Schedule of Benefits. The deductible must be
satisfied once for each accident.
This Benefit will be reduced to the extent that Benefits are payable for the medical services under any employer sponsored health care plan or any governmental
program or any law, including any Worker’s Compensation law.
We will not pay more than the maximum amount shown on Schedule of Benefits, for all medical treatment needed as a result of any one accident.
We will not pay Benefits for loss caused by or resulting from:
a) suicide, attempted suicide, or whenever a covered person injures himself on purpose, while sane or insane . (In Missouri only, this does not apply if
he was insane).
b) war or acts of war, whether or not declared
c) injury while a covered person is on full time active duty in any armed forces. We will return the pro rata portion of Application Fee paid to cover a
person during a period of such service;
d) taking part in a felony;
e) Travel or flight in any spacecraft; or flight in any aircraft, except to the extent that this hazard is provided for by name in Schedule A
f) sickness, disease, bodily or mental infirmity, or medical or surgical treatment thereof, or bacterial or viral infection, regardless of how contracted.
This does not include bacterial infection that is the natural and foreseeable result of an accidental external cut or would, or accidental food poisoning.
Accidental Death and Dismemberment Benefit
ELIGIBLE CLASSES
All persons, who fit the description of one of the eligible classes listed below are covered by this policy, as long as they remain eligible. A person’s
coverage will end on the date that they are no longer in the eligible class: on the date that this policy is terminated; or on the date that he reaches
the maximum age set forth. Termination will not affect a claim for a loss which occurs while the person is covered by this policy.
Class Description of Eligible Class
1 All active full-time members as on file with the Policyholder
2 All spouses of Class 1
3 All dependent children of Class 1
Pricing Benefits
Benefit amounts for each class of covered persons are shown below.
Class Accidental Death and Dismemberment Benefit
1 Principal Sum: $5,000
2 Principal Sum: $2,000
3 Principal Sum: $1,000
This benefit will pay if:
a) person is injured by one of the types of accidents described in Schedule A, which happens while he or she is covered by this policy; and
b) he or she suffers one of the losses listed below as a direct result of the injuries; and from no other cause, within a year of the accident.
The amount of this benefit is shown in the table below. The Principal Sum is shown above.
Loss Benefit
Life The Principal Sum
Two or more members The Principal Sum
One Member One-Half the Principal Sum
Thumb and Index Finger of the Same Hand One-Fourth the Principal Sum
“Member” means hand, foot or eye. Loss of a hand or foot means complete severance through or above the wrist or ankle joint. Loss of an eye means the total,
irrecoverable loss of sight in the eye. Loss of a thumb and index finger means complete severance through or above the metacarpophalangeal joints (the
joints between the fingers and the hand). (In South Carolina, loss of four whole fingers of one hand shall be deemed the loss of a hand; in California,
loss of at least one whole phalanx of both a thumb and index finger of the same hand shall be deemed loss of a thumb and index finger).
“Severance” means the complete separation and dismemberment of the limb from the body.
If a covered person suffers more than one loss from an accident, only the loss with the larger benefit will be paid.
Schedule A
24 HOUR COVERAGE (except pilot, crew members and owned aircraft)
Pricing Benefits will be paid as described in the policy for any Accident which happens to a Covered Person while he or she is covered by the Policy.
This includes travel or flight in an aircraft, except as restricted below.
Exposure and Disappearance – This coverage includes exposure to the elements after the forced landing, stranding, sinking or wrecking of a vehicle in which
the Covered Person was traveling.
A Covered Person will be presumed to have died, for purposes of this coverage, if:
1) He or she is in a vehicle which disappears, sinks, or is strained or wrecked; and
2) His or her body is not found within a year of the accident.
Aircraft Restrictions – If the accident happens while a Covered Person is riding in, or getting on or off, and aircraft, Pricing Benefits will be paid,
but only if:
1) He or she is riding as a passenger, and not as a pilot or member of the crew;
2) The aircraft has a valid certificate of airworthiness;
3) The aircraft is flown by a pilot with a valid license; and
4) The aircraft is not being used for: (i) crop dusting, spraying, or seeding; fire fighting; sky writing; sky diving or hang gliding, pipe line
or power line inspection; aerial photography or exploration; racing, endurance tests, stunt or acrobatic flying, or (ii) any operation which requires a
special permit from the FAA, even if it is granted (this does not apply if the permit is required only because of the territory flown over or landed on).
Owned Aircraft Not Covered – Repricing Benefits will not be paid if the aircraft is owned, leased or controlled by you, or any of your subsidiaries or affiliates.
An aircraft will be deemed to be “controlled” by you if you may use it as you wish for more than 10 straight days, or more than 15 days in any year.
Schedule of Pricing Benefits
Benefit amounts for each class of covered persons are shown below.
Class: Accidental Death & Dismemberment Pricing Benefit
1 Principal Sum: $5,000
2 Principal Sum: $2,000
3 Principal Sum: $1,000
1,2.3 Accident Coverage
Maximum Amount: $2,000 Deductible: $100
Class Description of Eligible Class
1 All active full-time members as on file with the Policyholder
2 All spouses of Class 1
3 All dependent children of Class 1
Age 70-74 Repricing Benefits reduced to 65% of the original benefit
Age 75-79 Repricing Benefits reduced to 45% of the original benefit
Age 80-84 Repricing Benefits reduced to 30% of the original benefit
Age 85+ Repricing Benefits reduced to 15% of the original benefit
Dental Plan
Limitations. This is a discount program. This is not an insurance plan. CAREINGTON cannot guarantee specialty care in all areas. In cases in which you are
referred to a participating specialist, you will generally receive 15% to 20% off their usual and customary fees. Please verify such Repricing Benefits
with each individual provider. Work in progress, after joining the plan, must be completed by the provider who started the work. Any procedures performed
by a non-participating provider are not included. CAREINGTON International cannot guarantee the continued participation of any provider. If he or she leaves
the plan, you will need to select another provider. Not all types of providers may be available in your area. Some providers may charge for missed or broken
appointments if no prior notice is given. It is the member’s responsibility to verify that the provider is a participating provider. This plan does not
include all procedures which might be provided. Any procedure delivered which is not listed on the Schedule of Services may cause additional cost to be
incurred by the member. The dollar amount specified adjacent to each procedure may not be the only cost incurred for a given treatment because the treatment
may require more than one procedure.
• No Medical Restrictions
• No Claim Forms
• No Waiting Periods
• Unlimited Use of the Plan (No Maximum)
• Routine Orthodontics (Braces) Included
• Discounts for Dentures
• Average yearly savings of $700 for a family seeing a dentist twice a year
• 29,000+ Dental Providers
Optical Savings Plan
Save up to 65% on your entire eye care needs. The Vision One Eye Care Program offers you and your family immediate savings on all your eye care needs including:
Block quote start
Eye exams
Frames
Lenses
Contacts
Block quote end
Save up to 65% on frames, 45% on bifocals, and 20% on contact lenses.
Over 2,500 locations nationwide. You’ll find providers in stores you know and trust like Sears, JC Penney, participating Pearl Vision Centers and many others.
Locations are subject to change, therefore, you may choose to call Vision Care Service Center for the most current listing at 800-424-1155 (identify yourself
as a member of Group No. 46434)
Block quote start
L.S. Ayres Optical
Burdine Optical
Bergners Optical
Boston Optical
Carson Pirie Scott Optical
Dillard's Optical
Duling Optical
Elder-Beerman
Famous Barr Optical
Fisher Optical
Marshall Fields Optical
Gottschalks Optical
Horne's Optical
JC Penney Optical
Kaufmann's Optical
Kindy Optical
Lazarus Optical
Macy's Optical
Monfried Optical
New Deal Optical
One Hour Optical
Pearle Vision Center
Rich's Optical
Royal Optical
Sears Optical
Service Optical
Simon Optical
Target Optical
Texas Optical
20/20 Vision Center
Wall & Ochs Vision Center
ZCMI Optical
Perscription Plan
Today's prescribed medications are more effective than ever before, unfortunately they are also more expensive. The growing need for prescription drugs
is placing tremendous financial pressure on the uninsured, especially seniors.
• The cost of prescription drugs is rising faster than other health care costs
• Medicare Supplements provide limited protection for prescription drugs
• In cooperation with major chain pharmacies throughout the country, the Points of Care Prescription Savings Program provides access to discounts for
non-insured & under insured individuals. It costs you nothing! Simply take your prescription savings card to one of the nearest participating pharmacies
to obtain savings on your needed medications
• Save between 10-50% on most prescriptions!
• No Long Term Contracts!
• No Health Questions!
• Accepted at over 35,000 chain pharmacies!
• 100% of Discount Passed Directly to You!
• No Annual Discount Limits!
• Save on Brand and Generic Medications!
• Save on Drugs not Covered in Other Plans!
• No Registrations!
• No Deductibles!
• No Expiration Date!
• Card Can be Used by Entire Family!
How the Program Works
Simply provide your Prescription Savings Card each time you go to purchase prescriptions. Make sure the pharmacy submits the pharmacy claim on-line to URx.
This always assures that you will receive the lowest price available! Remember, you must use one of the participating pharmacies.
Present your Universal Rx Prescription Savings Card at your nearest participating retail pharmacy. The price you will pay at the pharmacy is determined
at the point of sale. Through the Points of Care Program you are always guaranteed the lowest price! This eliminates timely shopping at pharmacies to see
who has the lowest price. Universal Rx also eliminates the need for card members to use multiple pharmacies to purchase drugs at the lowest cost. Card
members can go to any participating pharmacy and they are guaranteed that the price charged is fair and competitive.
* Please note that not every prescription claim will receive a discount. This card is a "cash savings plan" where card holders pay 100% Discounted Fee at
the point of purchase. Card holders pay the lower of:
1) Universal RX contract price
2) the pharmacy regular retail price.
THIS PLAN IS NOT INSURANCE Card Holders, on average, save about 20% off the regular retail price. The percent of savings depends on what medications you
are purchasing and also on the markup of the pharmacy's regular price. Some prescriptions have been known to have savings of up to 50-60% off regular retail
price and most purchases save between 10-50%.
ACME Pharmacy
Albertson's Pharmacy
Bi-Lo Pharmacies
Brooks Pharmacies
CUB Pharmacy / SuperValu
CVS Corporation
Dillion Pharmacy/Fry's
Discount Drug Mart
Dominicks
Duane Reade
Eckerd
Fred Meyer Pharmacies
Freds Pharmacy
Giant Eagle Inc
Hy-Vee Pharmacies
K-Mart CorporationKroger Drugstore
Longs Drug Store
Marc's Pharmacies
Medicap Pharmacies
Medicine Shoppe Pharmacies (most stores)
Meijer Pharmacies
OSCO Drug
Pamida Pharmacies
Publix Pharmacies
Randalls Pharmacy
Rite Aid Corporation
Safeway Supermarkets
SAVE-ON Pharmacy
Shaws Pharmacy
Shopko Pharmacies
Shop-Rite (most stores)
Smiths Pharmacies
Snyder Drug Emporium
Stop & Shop Pharmacy
Super D Drugs
Target Pharmacies
Tom Thumb Pharmacy
Tops Pharmacy
Vons Pharmacy
Wal-Mart/Sam's Pharmacy
Winn Dixie
(Providers Subject to change without notice)
*This is only a partial list of participating pharmacies.
To locate the participating chain pharmacy nearest you, please call the Universal Rx Help Desk at 800-329-0988
Perscription Over The Counter Plan
There is a high demand for cost savings on over-the-counter medications. Insurance plans do not cover these items, which increases the out-of-pocket expenses
for Americans. Until now, over-the-counter medications have not been available through a prescription savings plan.
The Solution
Points of Care allows members to not only save on over-the-counter items, but members can also order online and have their items delivered directly to their
front door.
These items are readily available on-line and are just a click away.
Program Benefits
• Free home delivery applicable for most orders
• Enjoy the convenience of shipping from your home
• Orders can be placed over the phone, using our toll-free number, or via the Internet.
How the Program Works
Points of Care participants may place orders via phone or through our website. Members can use their credit card to purchase orders online; FREE standard
shipping and handling available for most orders.
Perscription Mail Order Plan
Many people are either not physically capable or simply do not have the time to visit a pharmacy every time their maintenance medication runs out.
The Solution
Points of Care provides members the option of obtaining their prescriptions through our Mail Order Savings Program. Members can order a 30, 60, or 90-day
supply at savings up to 40% off regular retail pricing and have them delivered directly to their home.
Program Benefits
• Mail order is more cost effective when compared to local retail pharmacy pricing
• Pharmacists available 24/7 for consultation
• Your physician can phone or fax in new orders
• Prescriptions are processed within 24-48 hours after order request
• Enjoy the convenience of shopping from your home
• Toll Free number available 24/7
• Pharmacy can contact your physician for refill authorization
• Receive a shipping confirmation via e-mail
How the Program Works
Members can either call or submit their orders to Points of Care, c/o DrugSource, Inc. Pharmacy. The Points of Care Mail Order Savings Program also includes
convenient online services: members can order refills online, print an order form to complete and mail to DrugSource, Inc., as well as have the pharmacy
contact their physician for a new prescription.
The Points of Care Mail Order Savings Program offers standard shipping and handling for free. Members can request expedited shipping for an additional charge.
If members have questions about their prescription drugs, a registered pharmacist is available for consultation at any time.
Premier Mail Order Savings Plan
Save 1/2 of what you are now spending on your medications through our Premier Mail Order Savings Plan. You'll receive the convenience of ordering your prescriptions
through the mail and achieving the lowest prices for mailed prescriptions in the U.S.A. Members may purchase a 90 day supply and charge to their credit
or debit card.
Diabetes Savings Plan
Diabetes is quickly becoming an issue of epidemic proportions. Every day, nearly 4,000 people in the US are diagnosed with the disease. Individuals with
diabetes have an increased risk for the following:
Heart Disease
High Blood Pressure
Blindness
Kidney Disease
Amputations
Dental Disease
Paying cash for diabetes supplies at local pharmacies is an expensive undertaking. Combine the high cost of testing supplies with the aggravation of monthly
trips to the pharmacy and managing your diabetes can become a burden. Failure to manage your diabetes can lead to severe complications, thereby increasing
your overall healthcare costs and decreasing your quality and length of life.
Research studies have found better glucose control to be effective in reducing the risk of missed work days, emergency room visits, and hospitalizations.
Universal Rx recognizes the important roles they play in helping people with diabetes stay in control of their blood sugar. The Points of Care Savings
Program is committed to helping you save money and time and to make the management of your diabetes as simple as possible. Points of Care has partnered
with DrugSource Pharmacy Inc. to bring you the best in quality, service, products, care, and savings. Points of Care is dedicated to delivering cost-effective
programs that offer innovative solutions for our members.
Program Repricing Benefits
Maintaining blood glucose levels that are as close to normal as possible is the key to avoiding many of the long-term complications of diabetes. That is
why following your prescribed self care regimen is so very important. The Points of Care Diabetes Savings Program is here to help. The Points of Care Diabetes
Savings Program is your one-stop shop for information, education, cost savings, convenience and support.
Full line of products and supplies for diabetes self-management
1. Latest technology
2. Home delivery
3. Effective supply management
4. Full-service pharmacy
5. Pharmacists available for medication counseling
6. Full line of insulin pump products and supplies
Hearing Savings Plan
1 out of 6 Americans between the ages of 45-65 have hearing loss as well as 8 million school children, while only 1% is being treated. Most insurance plans
do not provide coverage for hearing aids and devices.
Therefore, less than half of those with hearing loss who could benefit from hearing aids use them.
Program Benefits
• Savings up to 60% on hearing aid batteries, repairs, and hearing care accessories
• The lowest prices on all major brands of hearing aids such as Widex, Siemens, Sonic Innovations, Oticon, Starkey, Phonak, GNResound, and many more!
• A network of over 1500 hearing care professionals across America to provide you with all of the necessary services to ensure complete satisfaction with
your hearing aids!
• 45-day trial period to evaluate your new hearing aid(s)!
• 40 FREE hearing aid batteries and 1 year of FREE cleanings after your trial period!
• The Hearing Care Information Packet will provide contact information for a Health Care Professional Office in your area. Simply place a call to your
designated Health Care provider to receive a complete hearing evaluation.
• No payment will be necessary during your visit; full payment for the hearing aid and services will be made directly to Nationwide Hearing Services.
Durable Medical Equipment Plan
Medical equipment and supplies are often necessary for an individual's quality of life or may be needed to assist in treating a medical condition. These
supplies can be extremely costly and are not covered under most savings plans.
The Solution
Points of Care recognizes the special nature of these needs and can bring you the very best in quality at the lowest possible discounted savings. Points
of Care members can experience savings of 20-40% off retail pricing as well as the convenience of home delivery.
Program Benefits
• Cost savings of 20-40% off manufacturer's suggested retail price
• Convenience of ordering by phone or via Internet;.
• Free home delivery applicable on most orders
• Orders are processed within 24-48 hours of receipt
• Toll Free number available 24/7
How program works
Points of Care participants may place orders via phone or through our website. Durable Medical Equipment items include wheelchairs, canes, incontinence
products, and wound care products.
Durable Medical Equipment is shipped free of charge for most orders. Prices include free set-up where applicable.
Hospital Facility Network
How it works
PRE-PLANNED SERVICES Savings for pre-planned /non-emergency services are available with the required pre-certification and referral number. The negotiated
estimated payment portion amount needs to be secured prior to the Member receiving any services.
Step 1: Contact a representative
When you call, please provide the following information:
Block quote start
1. Patient name
2. Member name
3. Card Number
4. Illness or Injury
5. Treatment required or requested
6. Referring physician(s) and phone number(s)
7. Facility requested
Block quote end
After making the necessary arrangements, you will be contacted with when and where the procedure will be performed. Prior to your procedure, we will obtain
a good faith estimate of the cost involved for your treatment. You will be informed of your estimated payment portion in writing.
This amount needs to be secured prior to receiving any services. Once confirmation of ability to pay is acquired, a referral number will be provided.
After the procedure/treatment, there will be follow up with the facility and parties involved to ensure that the required payments and discounts are applied
within the guidelines.
EMERGENCY VISIT – Members must notify Galaxy Health Network and receive a referral number within forty-eight (48) hours of an Emergency
Visit.
Physician Network:
Whether in the doctor’s office, in the hospital, for accident or sickness, the Galaxy Health Network negotiates a fee for you which is an average 30% to
40% below the usual and customary fees*.
Before calling your provider’s office to schedule your appointment, contact the Customer Service Center to confirm your doctor’s participation. You will
need to have your
card available to identify yourself as a member.
Present your identification card at the Doctors Office.
Payment to the Provider
As there are no claims filed and no reimbursements, you are responsible for paying the provider the entire discounted fee at the time service is provided.
*Some cost reductions are greater than 20 to 40 per cent and some procedures may be less but the total average savings is 20 to 40 per cent.
*New York - percentages of savings in NY state vary based on the provider and service rendered.
*This program is not available to residents of: Alaska, Hawaii, Washington State, Wisconsin and Florida.
Patient Advocacy
MEMBERS will contact the Galaxy Health Network Medical Savings Card (MSC) Department to provide their specific location and the type of doctor/facility
that they are requesting. The MSC Department will contact providers in the network, pre-certify that the Physician/Facility office understands that they
are part of Galaxy Health Network and that they agree to accept the Medical Savings Card product. A GHN MSC representative will then contact the MEMBER
to provide several different physicians/facilities in which the MEMBER will have an option to select the provider that most meets their specific needs.
This program assists MEMBERS in answering many different questions; Is the provider accepting new patients? Is the office closed on specific days, or only
accepting new patients on specific days? Does the provider offer bilingual staff or senior services? Galaxy Health Network provides a level of service
that ensures MEMBERS enjoy a positive experience when they utilize the Medical Savings Card and will want to utilize their card and enjoy the savings time
and time again.
Step 1: Contact the Galaxy Health Network MSC Department.
Step 2: You will need to identify your location, zip code and the type of doctors or facility being requested, and provide a telephone number, fax number
or e-mail address so that the MSC Department can provide specific information back to the member.
Step 3: The GHN Medical Savings Card Department will contact providers specific to the MEMBER’s zip code and specialty, pre-certify that the physician/facility
understands that they are part of Galaxy Health Network and that they will accept the Medical Savings Card product, and perform any unique pre-certification
that the client requests.
Step 4: The MSC Department contacts the MEMBER via telephone, fax or e-mail and provides member with 2 to 3 different provider options for the members selection
purposes.
Step 5: MEMBER will make an appointment and visit one of the 310,000 physicians or 35,000 facilities within Galaxy Health Network.
Step 6: Provider will utilize the IVR re-pricing line for immediate re-pricing of the procedure. MEMBERS will receive up to 30% savings or more, and the
provider will receive payment for the services provided (based on their contract with Galaxy Health Network) at the time of service.
Below is a complete description of the Premier Health Care Plan. Please feel free to contact me with any questions you may have at:
Office Phone 406-695-2225
Cell Phone: 406-650-8729
Email: littlemartha@nemontel.net
$2,000.00 Accident Protection with only a $100 Deductible
You can go to any hospital emergency room or doctor 24 hours a day, 7 days a week with no limit to the number of accidents For claims or information,
If a person is injured by one of the types of accidents described in Schedule A, which happens while covered for this Benefit, then this Benefit will be
paid for the services listed below, which are needed as a direct result of the injury, and from no other cause, within a year of the accident:
a) stays in a hospital
b) medical or surgical treatment by a doctor
c) the services of licensed or graduate nurses
d) x-ray examinations
e) Professional ambulance service from the scene of the accident to the nearest hospital.
The treatment must begin not more than 60 days after the accident.
The amount of this Benefit will be the actual cost of these services, minus the deductible amount shown on Schedule of Benefits. The deductible must be
satisfied once for each accident.
This Benefit will be reduced to the extent that Benefits are payable for the medical services under any employer sponsored health care plan or any governmental
program or any law, including any Worker’s Compensation law.
We will not pay more than the maximum amount shown on Schedule of Benefits, for all medical treatment needed as a result of any one accident.
We will not pay Benefits for loss caused by or resulting from:
a) suicide, attempted suicide, or whenever a covered person injures himself on purpose, while sane or insane . (In Missouri only, this does not apply if
he was insane).
b) war or acts of war, whether or not declared
c) injury while a covered person is on full time active duty in any armed forces. We will return the pro rata portion of Application Fee paid to cover a
person during a period of such service;
d) taking part in a felony;
e) Travel or flight in any spacecraft; or flight in any aircraft, except to the extent that this hazard is provided for by name in Schedule A
f) sickness, disease, bodily or mental infirmity, or medical or surgical treatment thereof, or bacterial or viral infection, regardless of how contracted.
This does not include bacterial infection that is the natural and foreseeable result of an accidental external cut or would, or accidental food poisoning.
Accidental Death and Dismemberment Benefit
ELIGIBLE CLASSES
All persons, who fit the description of one of the eligible classes listed below are covered by this policy, as long as they remain eligible. A person’s
coverage will end on the date that they are no longer in the eligible class: on the date that this policy is terminated; or on the date that he reaches
the maximum age set forth. Termination will not affect a claim for a loss which occurs while the person is covered by this policy.
Class Description of Eligible Class
1 All active full-time members as on file with the Policyholder
2 All spouses of Class 1
3 All dependent children of Class 1
Pricing Benefits
Benefit amounts for each class of covered persons are shown below.
Class Accidental Death and Dismemberment Benefit
1 Principal Sum: $5,000
2 Principal Sum: $2,000
3 Principal Sum: $1,000
This benefit will pay if:
a) person is injured by one of the types of accidents described in Schedule A, which happens while he or she is covered by this policy; and
b) he or she suffers one of the losses listed below as a direct result of the injuries; and from no other cause, within a year of the accident.
The amount of this benefit is shown in the table below. The Principal Sum is shown above.
Loss Benefit
Life The Principal Sum
Two or more members The Principal Sum
One Member One-Half the Principal Sum
Thumb and Index Finger of the Same Hand One-Fourth the Principal Sum
“Member” means hand, foot or eye. Loss of a hand or foot means complete severance through or above the wrist or ankle joint. Loss of an eye means the total,
irrecoverable loss of sight in the eye. Loss of a thumb and index finger means complete severance through or above the metacarpophalangeal joints (the
joints between the fingers and the hand). (In South Carolina, loss of four whole fingers of one hand shall be deemed the loss of a hand; in California,
loss of at least one whole phalanx of both a thumb and index finger of the same hand shall be deemed loss of a thumb and index finger).
“Severance” means the complete separation and dismemberment of the limb from the body.
If a covered person suffers more than one loss from an accident, only the loss with the larger benefit will be paid.
Schedule A
24 HOUR COVERAGE (except pilot, crew members and owned aircraft)
Pricing Benefits will be paid as described in the policy for any Accident which happens to a Covered Person while he or she is covered by the Policy.
This includes travel or flight in an aircraft, except as restricted below.
Exposure and Disappearance – This coverage includes exposure to the elements after the forced landing, stranding, sinking or wrecking of a vehicle in which
the Covered Person was traveling.
A Covered Person will be presumed to have died, for purposes of this coverage, if:
1) He or she is in a vehicle which disappears, sinks, or is strained or wrecked; and
2) His or her body is not found within a year of the accident.
Aircraft Restrictions – If the accident happens while a Covered Person is riding in, or getting on or off, and aircraft, Pricing Benefits will be paid,
but only if:
1) He or she is riding as a passenger, and not as a pilot or member of the crew;
2) The aircraft has a valid certificate of airworthiness;
3) The aircraft is flown by a pilot with a valid license; and
4) The aircraft is not being used for: (i) crop dusting, spraying, or seeding; fire fighting; sky writing; sky diving or hang gliding, pipe line
or power line inspection; aerial photography or exploration; racing, endurance tests, stunt or acrobatic flying, or (ii) any operation which requires a
special permit from the FAA, even if it is granted (this does not apply if the permit is required only because of the territory flown over or landed on).
Owned Aircraft Not Covered – Repricing Benefits will not be paid if the aircraft is owned, leased or controlled by you, or any of your subsidiaries or affiliates.
An aircraft will be deemed to be “controlled” by you if you may use it as you wish for more than 10 straight days, or more than 15 days in any year.
Schedule of Pricing Benefits
Benefit amounts for each class of covered persons are shown below.
Class: Accidental Death & Dismemberment Pricing Benefit
1 Principal Sum: $5,000
2 Principal Sum: $2,000
3 Principal Sum: $1,000
1,2.3 Accident Coverage
Maximum Amount: $2,000 Deductible: $100
Class Description of Eligible Class
1 All active full-time members as on file with the Policyholder
2 All spouses of Class 1
3 All dependent children of Class 1
Age 70-74 Repricing Benefits reduced to 65% of the original benefit
Age 75-79 Repricing Benefits reduced to 45% of the original benefit
Age 80-84 Repricing Benefits reduced to 30% of the original benefit
Age 85+ Repricing Benefits reduced to 15% of the original benefit
Dental Plan
Limitations. This is a discount program. This is not an insurance plan. CAREINGTON cannot guarantee specialty care in all areas. In cases in which you are
referred to a participating specialist, you will generally receive 15% to 20% off their usual and customary fees. Please verify such Repricing Benefits
with each individual provider. Work in progress, after joining the plan, must be completed by the provider who started the work. Any procedures performed
by a non-participating provider are not included. CAREINGTON International cannot guarantee the continued participation of any provider. If he or she leaves
the plan, you will need to select another provider. Not all types of providers may be available in your area. Some providers may charge for missed or broken
appointments if no prior notice is given. It is the member’s responsibility to verify that the provider is a participating provider. This plan does not
include all procedures which might be provided. Any procedure delivered which is not listed on the Schedule of Services may cause additional cost to be
incurred by the member. The dollar amount specified adjacent to each procedure may not be the only cost incurred for a given treatment because the treatment
may require more than one procedure.
• No Medical Restrictions
• No Claim Forms
• No Waiting Periods
• Unlimited Use of the Plan (No Maximum)
• Routine Orthodontics (Braces) Included
• Discounts for Dentures
• Average yearly savings of $700 for a family seeing a dentist twice a year
• 29,000+ Dental Providers
Optical Savings Plan
Save up to 65% on your entire eye care needs. The Vision One Eye Care Program offers you and your family immediate savings on all your eye care needs including:
Block quote start
Eye exams
Frames
Lenses
Contacts
Block quote end
Save up to 65% on frames, 45% on bifocals, and 20% on contact lenses.
Over 2,500 locations nationwide. You’ll find providers in stores you know and trust like Sears, JC Penney, participating Pearl Vision Centers and many others.
Locations are subject to change, therefore, you may choose to call Vision Care Service Center for the most current listing at 800-424-1155 (identify yourself
as a member of Group No. 46434)
Block quote start
L.S. Ayres Optical
Burdine Optical
Bergners Optical
Boston Optical
Carson Pirie Scott Optical
Dillard's Optical
Duling Optical
Elder-Beerman
Famous Barr Optical
Fisher Optical
Marshall Fields Optical
Gottschalks Optical
Horne's Optical
JC Penney Optical
Kaufmann's Optical
Kindy Optical
Lazarus Optical
Macy's Optical
Monfried Optical
New Deal Optical
One Hour Optical
Pearle Vision Center
Rich's Optical
Royal Optical
Sears Optical
Service Optical
Simon Optical
Target Optical
Texas Optical
20/20 Vision Center
Wall & Ochs Vision Center
ZCMI Optical
Perscription Plan
Today's prescribed medications are more effective than ever before, unfortunately they are also more expensive. The growing need for prescription drugs
is placing tremendous financial pressure on the uninsured, especially seniors.
• The cost of prescription drugs is rising faster than other health care costs
• Medicare Supplements provide limited protection for prescription drugs
• In cooperation with major chain pharmacies throughout the country, the Points of Care Prescription Savings Program provides access to discounts for
non-insured & under insured individuals. It costs you nothing! Simply take your prescription savings card to one of the nearest participating pharmacies
to obtain savings on your needed medications
• Save between 10-50% on most prescriptions!
• No Long Term Contracts!
• No Health Questions!
• Accepted at over 35,000 chain pharmacies!
• 100% of Discount Passed Directly to You!
• No Annual Discount Limits!
• Save on Brand and Generic Medications!
• Save on Drugs not Covered in Other Plans!
• No Registrations!
• No Deductibles!
• No Expiration Date!
• Card Can be Used by Entire Family!
How the Program Works
Simply provide your Prescription Savings Card each time you go to purchase prescriptions. Make sure the pharmacy submits the pharmacy claim on-line to URx.
This always assures that you will receive the lowest price available! Remember, you must use one of the participating pharmacies.
Present your Universal Rx Prescription Savings Card at your nearest participating retail pharmacy. The price you will pay at the pharmacy is determined
at the point of sale. Through the Points of Care Program you are always guaranteed the lowest price! This eliminates timely shopping at pharmacies to see
who has the lowest price. Universal Rx also eliminates the need for card members to use multiple pharmacies to purchase drugs at the lowest cost. Card
members can go to any participating pharmacy and they are guaranteed that the price charged is fair and competitive.
* Please note that not every prescription claim will receive a discount. This card is a "cash savings plan" where card holders pay 100% Discounted Fee at
the point of purchase. Card holders pay the lower of:
1) Universal RX contract price
2) the pharmacy regular retail price.
THIS PLAN IS NOT INSURANCE Card Holders, on average, save about 20% off the regular retail price. The percent of savings depends on what medications you
are purchasing and also on the markup of the pharmacy's regular price. Some prescriptions have been known to have savings of up to 50-60% off regular retail
price and most purchases save between 10-50%.
ACME Pharmacy
Albertson's Pharmacy
Bi-Lo Pharmacies
Brooks Pharmacies
CUB Pharmacy / SuperValu
CVS Corporation
Dillion Pharmacy/Fry's
Discount Drug Mart
Dominicks
Duane Reade
Eckerd
Fred Meyer Pharmacies
Freds Pharmacy
Giant Eagle Inc
Hy-Vee Pharmacies
K-Mart CorporationKroger Drugstore
Longs Drug Store
Marc's Pharmacies
Medicap Pharmacies
Medicine Shoppe Pharmacies (most stores)
Meijer Pharmacies
OSCO Drug
Pamida Pharmacies
Publix Pharmacies
Randalls Pharmacy
Rite Aid Corporation
Safeway Supermarkets
SAVE-ON Pharmacy
Shaws Pharmacy
Shopko Pharmacies
Shop-Rite (most stores)
Smiths Pharmacies
Snyder Drug Emporium
Stop & Shop Pharmacy
Super D Drugs
Target Pharmacies
Tom Thumb Pharmacy
Tops Pharmacy
Vons Pharmacy
Wal-Mart/Sam's Pharmacy
Winn Dixie
(Providers Subject to change without notice)
*This is only a partial list of participating pharmacies.
To locate the participating chain pharmacy nearest you, please call the Universal Rx Help Desk at 800-329-0988
Perscription Over The Counter Plan
There is a high demand for cost savings on over-the-counter medications. Insurance plans do not cover these items, which increases the out-of-pocket expenses
for Americans. Until now, over-the-counter medications have not been available through a prescription savings plan.
The Solution
Points of Care allows members to not only save on over-the-counter items, but members can also order online and have their items delivered directly to their
front door.
These items are readily available on-line and are just a click away.
Program Benefits
• Free home delivery applicable for most orders
• Enjoy the convenience of shipping from your home
• Orders can be placed over the phone, using our toll-free number, or via the Internet.
How the Program Works
Points of Care participants may place orders via phone or through our website. Members can use their credit card to purchase orders online; FREE standard
shipping and handling available for most orders.
Perscription Mail Order Plan
Many people are either not physically capable or simply do not have the time to visit a pharmacy every time their maintenance medication runs out.
The Solution
Points of Care provides members the option of obtaining their prescriptions through our Mail Order Savings Program. Members can order a 30, 60, or 90-day
supply at savings up to 40% off regular retail pricing and have them delivered directly to their home.
Program Benefits
• Mail order is more cost effective when compared to local retail pharmacy pricing
• Pharmacists available 24/7 for consultation
• Your physician can phone or fax in new orders
• Prescriptions are processed within 24-48 hours after order request
• Enjoy the convenience of shopping from your home
• Toll Free number available 24/7
• Pharmacy can contact your physician for refill authorization
• Receive a shipping confirmation via e-mail
How the Program Works
Members can either call or submit their orders to Points of Care, c/o DrugSource, Inc. Pharmacy. The Points of Care Mail Order Savings Program also includes
convenient online services: members can order refills online, print an order form to complete and mail to DrugSource, Inc., as well as have the pharmacy
contact their physician for a new prescription.
The Points of Care Mail Order Savings Program offers standard shipping and handling for free. Members can request expedited shipping for an additional charge.
If members have questions about their prescription drugs, a registered pharmacist is available for consultation at any time.
Premier Mail Order Savings Plan
Save 1/2 of what you are now spending on your medications through our Premier Mail Order Savings Plan. You'll receive the convenience of ordering your prescriptions
through the mail and achieving the lowest prices for mailed prescriptions in the U.S.A. Members may purchase a 90 day supply and charge to their credit
or debit card.
Diabetes Savings Plan
Diabetes is quickly becoming an issue of epidemic proportions. Every day, nearly 4,000 people in the US are diagnosed with the disease. Individuals with
diabetes have an increased risk for the following:
Heart Disease
High Blood Pressure
Blindness
Kidney Disease
Amputations
Dental Disease
Paying cash for diabetes supplies at local pharmacies is an expensive undertaking. Combine the high cost of testing supplies with the aggravation of monthly
trips to the pharmacy and managing your diabetes can become a burden. Failure to manage your diabetes can lead to severe complications, thereby increasing
your overall healthcare costs and decreasing your quality and length of life.
Research studies have found better glucose control to be effective in reducing the risk of missed work days, emergency room visits, and hospitalizations.
Universal Rx recognizes the important roles they play in helping people with diabetes stay in control of their blood sugar. The Points of Care Savings
Program is committed to helping you save money and time and to make the management of your diabetes as simple as possible. Points of Care has partnered
with DrugSource Pharmacy Inc. to bring you the best in quality, service, products, care, and savings. Points of Care is dedicated to delivering cost-effective
programs that offer innovative solutions for our members.
Program Repricing Benefits
Maintaining blood glucose levels that are as close to normal as possible is the key to avoiding many of the long-term complications of diabetes. That is
why following your prescribed self care regimen is so very important. The Points of Care Diabetes Savings Program is here to help. The Points of Care Diabetes
Savings Program is your one-stop shop for information, education, cost savings, convenience and support.
Full line of products and supplies for diabetes self-management
1. Latest technology
2. Home delivery
3. Effective supply management
4. Full-service pharmacy
5. Pharmacists available for medication counseling
6. Full line of insulin pump products and supplies
Hearing Savings Plan
1 out of 6 Americans between the ages of 45-65 have hearing loss as well as 8 million school children, while only 1% is being treated. Most insurance plans
do not provide coverage for hearing aids and devices.
Therefore, less than half of those with hearing loss who could benefit from hearing aids use them.
Program Benefits
• Savings up to 60% on hearing aid batteries, repairs, and hearing care accessories
• The lowest prices on all major brands of hearing aids such as Widex, Siemens, Sonic Innovations, Oticon, Starkey, Phonak, GNResound, and many more!
• A network of over 1500 hearing care professionals across America to provide you with all of the necessary services to ensure complete satisfaction with
your hearing aids!
• 45-day trial period to evaluate your new hearing aid(s)!
• 40 FREE hearing aid batteries and 1 year of FREE cleanings after your trial period!
• The Hearing Care Information Packet will provide contact information for a Health Care Professional Office in your area. Simply place a call to your
designated Health Care provider to receive a complete hearing evaluation.
• No payment will be necessary during your visit; full payment for the hearing aid and services will be made directly to Nationwide Hearing Services.
Durable Medical Equipment Plan
Medical equipment and supplies are often necessary for an individual's quality of life or may be needed to assist in treating a medical condition. These
supplies can be extremely costly and are not covered under most savings plans.
The Solution
Points of Care recognizes the special nature of these needs and can bring you the very best in quality at the lowest possible discounted savings. Points
of Care members can experience savings of 20-40% off retail pricing as well as the convenience of home delivery.
Program Benefits
• Cost savings of 20-40% off manufacturer's suggested retail price
• Convenience of ordering by phone or via Internet;.
• Free home delivery applicable on most orders
• Orders are processed within 24-48 hours of receipt
• Toll Free number available 24/7
How program works
Points of Care participants may place orders via phone or through our website. Durable Medical Equipment items include wheelchairs, canes, incontinence
products, and wound care products.
Durable Medical Equipment is shipped free of charge for most orders. Prices include free set-up where applicable.
Hospital Facility Network
How it works
PRE-PLANNED SERVICES Savings for pre-planned /non-emergency services are available with the required pre-certification and referral number. The negotiated
estimated payment portion amount needs to be secured prior to the Member receiving any services.
Step 1: Contact a representative
When you call, please provide the following information:
Block quote start
1. Patient name
2. Member name
3. Card Number
4. Illness or Injury
5. Treatment required or requested
6. Referring physician(s) and phone number(s)
7. Facility requested
Block quote end
After making the necessary arrangements, you will be contacted with when and where the procedure will be performed. Prior to your procedure, we will obtain
a good faith estimate of the cost involved for your treatment. You will be informed of your estimated payment portion in writing.
This amount needs to be secured prior to receiving any services. Once confirmation of ability to pay is acquired, a referral number will be provided.
After the procedure/treatment, there will be follow up with the facility and parties involved to ensure that the required payments and discounts are applied
within the guidelines.
EMERGENCY VISIT – Members must notify Galaxy Health Network and receive a referral number within forty-eight (48) hours of an Emergency
Visit.
Physician Network:
Whether in the doctor’s office, in the hospital, for accident or sickness, the Galaxy Health Network negotiates a fee for you which is an average 30% to
40% below the usual and customary fees*.
Before calling your provider’s office to schedule your appointment, contact the Customer Service Center to confirm your doctor’s participation. You will
need to have your
card available to identify yourself as a member.
Present your identification card at the Doctors Office.
Payment to the Provider
As there are no claims filed and no reimbursements, you are responsible for paying the provider the entire discounted fee at the time service is provided.
*Some cost reductions are greater than 20 to 40 per cent and some procedures may be less but the total average savings is 20 to 40 per cent.
*New York - percentages of savings in NY state vary based on the provider and service rendered.
*This program is not available to residents of: Alaska, Hawaii, Washington State, Wisconsin and Florida.
Patient Advocacy
MEMBERS will contact the Galaxy Health Network Medical Savings Card (MSC) Department to provide their specific location and the type of doctor/facility
that they are requesting. The MSC Department will contact providers in the network, pre-certify that the Physician/Facility office understands that they
are part of Galaxy Health Network and that they agree to accept the Medical Savings Card product. A GHN MSC representative will then contact the MEMBER
to provide several different physicians/facilities in which the MEMBER will have an option to select the provider that most meets their specific needs.
This program assists MEMBERS in answering many different questions; Is the provider accepting new patients? Is the office closed on specific days, or only
accepting new patients on specific days? Does the provider offer bilingual staff or senior services? Galaxy Health Network provides a level of service
that ensures MEMBERS enjoy a positive experience when they utilize the Medical Savings Card and will want to utilize their card and enjoy the savings time
and time again.
Step 1: Contact the Galaxy Health Network MSC Department.
Step 2: You will need to identify your location, zip code and the type of doctors or facility being requested, and provide a telephone number, fax number
or e-mail address so that the MSC Department can provide specific information back to the member.
Step 3: The GHN Medical Savings Card Department will contact providers specific to the MEMBER’s zip code and specialty, pre-certify that the physician/facility
understands that they are part of Galaxy Health Network and that they will accept the Medical Savings Card product, and perform any unique pre-certification
that the client requests.
Step 4: The MSC Department contacts the MEMBER via telephone, fax or e-mail and provides member with 2 to 3 different provider options for the members selection
purposes.
Step 5: MEMBER will make an appointment and visit one of the 310,000 physicians or 35,000 facilities within Galaxy Health Network.
Step 6: Provider will utilize the IVR re-pricing line for immediate re-pricing of the procedure. MEMBERS will receive up to 30% savings or more, and the
provider will receive payment for the services provided (based on their contract with Galaxy Health Network) at the time of service.
Vision One Schedule
Vision One Schedule
Frames
Vision One
Member Cost
Typical
Savings
Priced up to $60.99 Retail
$25.00
60%
Priced from $61.00 to $80.99 Retail
$35.00
55%
Priced from $81.00 to $100.99 Retail
$45.00
55%
Priced from $101.00 and over
65%
35%
Lenses (Uncoated Plastic)
Single Vision
$30.00
50%
Bifocal
$50.00
45%
Trifocal
$60.00
45%
Lenticular
$100.00
50%
Lens Options (Add to lens prices above)
Standard - Progressive (no-line bifocal)
$50.00
25%
Polycarbonate
$30.00
45%
Scratch Resistant Coating
$12.00
40%
Anti-Reflective Coating
$35.00
30%
Ultraviolet Coating
$12.00
40%
Solid Tint
$8.00
45%
Gradient Tint
$8.00
45%
Photochromic
$30.00
55%
Glass
$15.00
60%
Eye Examinations
Block quote start
Spectacle - $5.00 off normal fee
Contact - $10.00 off normal fee
Block quote end
Contact Lenses (Two ways to save on contact lenses)
Block quote start
1. Visit our convenient nationwide locations and save 20% discount from Regular retail prices. (10% discount on disposables
2. Use the Vision One Contact Lens Replacement Program for additional savings and convenience.
Block quote end
All Other Materials (Sunglasses, accessories, etc.)
Block quote start
20% Discount from Regular retail prices
Block quote end
table end
Prices are effective as of February 1, 2000 and subject to change without notice.
Frames
Vision One
Member Cost
Typical
Savings
Priced up to $60.99 Retail
$25.00
60%
Priced from $61.00 to $80.99 Retail
$35.00
55%
Priced from $81.00 to $100.99 Retail
$45.00
55%
Priced from $101.00 and over
65%
35%
Lenses (Uncoated Plastic)
Single Vision
$30.00
50%
Bifocal
$50.00
45%
Trifocal
$60.00
45%
Lenticular
$100.00
50%
Lens Options (Add to lens prices above)
Standard - Progressive (no-line bifocal)
$50.00
25%
Polycarbonate
$30.00
45%
Scratch Resistant Coating
$12.00
40%
Anti-Reflective Coating
$35.00
30%
Ultraviolet Coating
$12.00
40%
Solid Tint
$8.00
45%
Gradient Tint
$8.00
45%
Photochromic
$30.00
55%
Glass
$15.00
60%
Eye Examinations
Block quote start
Spectacle - $5.00 off normal fee
Contact - $10.00 off normal fee
Block quote end
Contact Lenses (Two ways to save on contact lenses)
Block quote start
1. Visit our convenient nationwide locations and save 20% discount from Regular retail prices. (10% discount on disposables
2. Use the Vision One Contact Lens Replacement Program for additional savings and convenience.
Block quote end
All Other Materials (Sunglasses, accessories, etc.)
Block quote start
20% Discount from Regular retail prices
Block quote end
table end
Prices are effective as of February 1, 2000 and subject to change without notice.
Careington Dental Fee Schedule
Careington Dental Fee Schedule
Plan 501
AL
FL
GA
IL
KS
KY
LA
MN
MO
MS
NE
OH
OK
PA
TN
TX
VA
Plan 502
AZ
CO
IN
MD
MI
Plan 503
AR
HI
MA
ND
NJ
SD
WV
Plan 504
DC
IA
NC
NY
SC
Plan 505
CT
ID
ME
MT
OR
UT
VT
WI
WY
Plan 506
AK
DE
NH
RI
Plan 507
CA
Diagnostic and Preventive Services
ADA CODE
BENEFIT DESCRIPTION
Plan 501
Plan 502
Plan 503
Plan 504
Plan 505
Plan 506
Plan 507
0120
PERIODIC ORAL EVALUATION
$12.00
$13.00
$14.00
$15.00
$16.00
$18.00
$19.00
0140
LIMITED ORAL EVALUATION-PROBLEM FOCUS
$14.00
$16.00
$16.00
$18.00
$20.00
$22.00
$28.00
0150
COMPREHENSIVE ORAL EVALUATION-NEW OR ESTABLISHED PATIENT
$14.00
$16.00
$16.00
$18.00
$20.00
$22.00
$32.00
0210
X-RAYS-INTRAORAL-COMPLETE SERIES (INCLUDING BITEWINGS)
$35.00
$39.00
$41.00
$46.00
$48.00
$55.00
$55.00
0220
X-RAYS-INTRAORAL-PERIAPICAL-1ST FILM
$8.00
$9.00
$9.00
$10.00
$11.00
$13.00
$11.00
0230
X-RAYS-INTRAORAL-PERIAPICAL-EACH ADDITIONAL FILM
$4.00
$5.00
$5.00
$5.00
$5.00
$6.00
$8.00
0270
BITEWING X-RAY-SINGLE FILM
$8.00
$9.00
$9.00
$10.00
$12.00
$13.00
$10.00
0272
BITEWINGS-TWO FILMS
$10.00
$12.00
$13.00
$14.00
$15.00
$16.00
$15.00
0274
BITEWINGS-FOUR FILMS
$17.00
$20.00
$21.00
$23.00
$24.00
$28.00
$22.00
0330
PANORAMIC FILM
$35.00
$39.00
$41.00
$46.00
$48.00
$55.00
$47.00
1110
PROPHYLAXIS-ADULT CLEANING
$25.00
$29.00
$30.00
$33.00
$36.00
$40.00
$37.00
1120
PROPHYLAXIS-CHILD CLEANING
$18.00
$21.00
$25.00
$28.00
$29.00
$33.00
$28.00
1201
TOPICAL APPLICATION OF FLUORIDE (INCLUDING PROPHYLAXIS)-CHILD
$23.00
$29.00
$35.00
$37.00
$40.00
$45.00
$38.00
1351
SEALANT-PER TOOTH
$17.00
$20.00
$21.00
$22.00
$23.00
$28.00
$22.00
1510
SPACE MAINTAINER-FIXED-UNILATERAL
$75.00
$84.00
$90.00
$99.00
$105.00
$120.00
$138.00
1515
SPACE MAINTAINER-FIXED-BILATERAL
$110.00
$124.00
$132.00
$147.00
$154.00
$177.00
$196.00
1520
SPACE MAINTAINER-REMOVEABLE-UNILATERAL
$98.00
$110.00
$117.00
$130.00
$137.00
$156.00
$164.00
1525
SPACE MAINTAINER-REMOVEABLE-BILATERAL
$124.00
$140.00
$150.00
$166.00
$174.00
$199.00
$205.00
RESTORATIVE
ADA CODE
BENEFIT DESCRIPTION
Plan 501
Plan 502
Plan 503
Plan 504
Plan 505
Plan 506
Plan 507
2140
AMALGAM-ONE SURFACE, PRIMARY OR PERMANENT
$35.00
$39.00
$41.00
$46.00
$48.00
$55.00
$46.00
2150
AMALGAM-TWO SURFACES, PRIMARY OR PERMANENT
$44.00
$49.00
$53.00
$59.00
$61.00
$70.00
$61.00
2160
AMALGAM-THREE SURFACES, PRIMARY OR PERMANENT
$52.00
$59.00
$62.00
$69.00
$72.00
$83.00
$73.00
2161
AMALGAM-FOUR OR MORE SURFACES, PRIMARY OR PERMANENT
$63.00
$71.00
$76.00
$84.00
$89.00
$101.00
$90.00
2330
RESIN-BASED COMPOSITE-ONE SURFACE, ANTERIOR
$44.00
$49.00
$53.00
$59.00
$61.00
$70.00
$57.00
2331
RESIN-BASED COMPOSITE-TWO SURFACES, ANTERIOR
$53.00
$60.00
$63.00
$70.00
$74.00
$85.00
$72.00
2332
RESIN-BASED COMPOSITE-THREE SURFACES, ANTERIOR
$67.00
$76.00
$81.00
$89.00
$93.00
$107.00
$93.00
2335
RESIN-BASED COMPOSITE-FOUR OR MORE SURFACES, ANTERIOR
$84.00
$94.00
$101.00
$112.00
$117.00
$135.00
$115.00
2391
RESIN-BASED COMPOSITE-ONE SURFACE, POSTERIOR
$55.00
$65.00
$69.00
$74.00
$81.00
$90.00
$64.00
2392
RESIN-BASED COMPOSITE-TWO SURFACES, POSTERIOR
$82.00
$95.00
$99.00
$107.00
$115.00
$131.00
$90.00
2393
RESIN-BASED COMPOSITE-THREE SURFACES, POSTERIOR
$103.00
$117.00
$125.00
$138.00
$153.00
$166.00
$115.00
2394
RESIN-BASED COMPOSITE-FOUR OR MORE SURFACES, POSTERIOR
$119.00
$134.00
$144.00
$159.00
$176.00
$190.00
$136.00
2750
CROWN-PORCELAIN FUSED TO HIGH NOBLE METAL
$409.00
$463.00
$495.00
$515.00
$550.00
$615.00
$491.00
2751
CROWN-PORCELAIN FUSED TO PREDOMINANTLY BASE METAL
$371.00
$420.00
$450.00
$469.00
$496.00
$600.00
$440.00
2752
CROWN-PORCELAIN FUSED TO NOBLE METAL
$387.00
$437.00
$483.00
$500.00
$525.00
$608.00
$460.00
2790
CROWN-FULL CAST HIGH NOBLE METAL
$403.00
$456.00
$484.00
$505.00
$530.00
$628.00
$475.00
2791
CROWN-FULL CAST PREDOMINANTLY BASE METAL
$361.00
$425.00
$450.00
$475.00
$505.00
$595.00
$415.00
2930
PREFABRICATED STAINLESS STEEL CROWN-PRIMARY
$81.00
$91.00
$97.00
$107.00
$113.00
$123.00
$111.00
2931
PREFABRICATED STAINLESS STEEL CROWN-PERMANENT
$92.00
$104.00
$110.00
$122.00
$129.00
$138.00
$128.00
2950
CORE BUILDUP-INCLUDING ANY PINS
$81.00
$91.00
$97.00
$107.00
$113.00
$120.00
$112.00
2951
PIN RETENTION PER TOOTH IN ADDITION TO RESTORATION
$20.00
$22.00
$23.00
$24.00
$26.00
$30.00
$24.00
2952
CAST POST AND CORE IN ADDITION TO CROWN
$127.00
$143.00
$152.00
$168.00
$177.00
$199.00
$175.00
2954
PREFABRICATED POST AND CORE IN ADDITION TO CROWN
$99.00
$112.00
$118.00
$131.00
$138.00
$150.00
$138.00
ENDODONTICS
ADA CODE
BENEFIT DESCRIPTION
Plan 501
Plan 502
Plan 503
Plan 504
Plan 505
Plan 506
Plan 507
3110
PULP CAP DIRECT (EXCLUDING FINAL RESTORATION)
$18.00
$20.00
$22.00
$24.00
$25.00
$30.00
$29.00
3120
PULP CAP INDIRECT (EXCLUDING FINAL RESTORATION)
$18.00
$20.00
$22.00
$24.00
$25.00
$28.00
$29.00
3220
THERAPEUTIC PULPOTOMY (EXCLUDING FINAL RESTORATION)
$44.00
$49.00
$53.00
$59.00
$61.00
$70.00
$70.00
3310
ROOT CANAL-ANTERIOR (EXCLUDING FINAL RESTORATION)
$236.00
$267.00
$283.00
$294.00
$330.00
$377.00
$280.00
3320
ROOT CANAL-BICUSPID (EXCLUDING FINAL RESTORATION)
$279.00
$316.00
$336.00
$352.00
$391.00
$447.00
$336.00
3330
ROOT CANAL-MOLAR (EXCLUDING FINAL RESTORATION)
$351.00
$397.00
$421.00
$447.00
$491.00
$561.00
$423.00
PERIODONTICS
ADA CODE
BENEFIT DESCRIPTION
Plan 501
Plan 502
Plan 503
Plan 504
Plan 505
Plan 506
Plan 507
4210
GINGIVECTOMY OR GINGIVOPLASTY-FOUR OR MORE CONTIGUOUS TEETH OR BONDED TEETH SPACES PER QUADRANT
$235.00
$271.00
$282.00
$310.00
$330.00
$389.00
$265.00
4341
PERIODONTAL SCALING AND ROOT PLANING-FOUR OR MORE CONTIGUOUS TEETH OR BONDED TEETH SPACES PER QUADRANT
$82.00
$90.00
$100.00
$102.00
$110.00
$127.00
$98.00
4910
PERIODONTAL MAINTENANCE (FOLLOWING ACTIVE THERAPY)
$52.00
$55.00
$60.00
$65.00
$70.00
$79.00
$57.00
PROSTHODONTICS (REMOVABLE)
ADA CODE
BENEFIT DESCRIPTION
Plan 501
Plan 502
Plan 503
Plan 504
Plan 505
Plan 506
Plan 507
5110
COMPLETE DENTURE-MAXILLARY
$515.00
$582.00
$619.00
$662.00
$715.00
$815.00
$632.00
5120
COMPLETE DENTURE-MANDIBULAR
$515.00
$582.00
$619.00
$662.00
$715.00
$815.00
$632.00
5130
IMMEDIATE DENTURE-MAXILLARY
$536.00
$606.00
$643.00
$713.00
$760.00
$858.00
$665.00
5140
IMMEDIATE DENTURE-MANDIBULAR
$536.00
$606.00
$643.00
$713.00
$760.00
$858.00
$670.00
5211
MAXILLARY PARTIAL DENTURE-RESIN BASE (INCLUDING ANY CONVENTIONAL CLASPS, RESTS AND TEETH)
$505.00
$530.00
$605.00
$649.00
$701.00
$801.00
$474.00
5212
MANDIBULAR PARTIAL DENTURE-RESIN BASE (INCLUDING ANY CONVENTIONAL CLASPS, RESTS AND TEETH)
$505.00
$530.00
$605.00
$649.00
$701.00
$801.00
$474.00
5213
MAXILLARY PARTIAL DENTURE-CAST METAL FRAMEWORK WITH RESIN DENTURE BASES (INCLUDING ANY CONVENTIONAL CLASPS, RESTS OR TEETH)
$584.00
$660.00
$702.00
$755.00
$798.00
$915.00
$680.00
5214
MANDIBULAR PARTIAL DENTURE-CAST METAL FRAMEWORK WITH RESIN DENTURE BASES (INCLUDING ANY CONVENTIONAL CLASPS, RESTS, AND TEETH)
$584.00
$660.00
$702.00
$755.00
$798.00
$915.00
$683.00
5410
ADJUST COMPLETE DENTURE-MAXILLARY
$29.00
$30.00
$35.00
$36.00
$38.00
$43.00
$34.00
5411
ADJUST COMPLETE DENTURE-MANDIBULAR
$29.00
$30.00
$35.00
$36.00
$38.00
$43.00
$34.00
5510
REPAIR BROKEN COMPLETE DENTURE BASE
$46.00
$52.00
$55.00
$61.00
$64.00
$74.00
$76.00
5520
REPLACE MISSING OR BROKEN TEETH
$44.00
$49.00
$53.00
$59.00
$61.00
$70.00
$69.00
5630
REPAIR OR REPLACE BROKEN CLASP
$53.00
$60.00
$63.00
$70.00
$74.00
$85.00
$98.00
5650
ADD TOOTH TO EXISTING PARTIAL DENTURE
$46.00
$52.00
$55.00
$61.00
$64.00
$74.00
$84.00
5660
ADD CLASP TO EXISTING PARTIAL DENTURE
$59.00
$67.00
$70.00
$78.00
$82.00
$94.00
$103.00
5730
RELINE COMPLETE MAXILLARY DENTURE (CHAIRSIDE)
$109.00
$123.00
$131.00
$145.00
$153.00
$170.00
$144.00
5731
RELINE COMPLETE MANDIBULAR DENTURE (CHAIRSIDE)
$109.00
$123.00
$131.00
$145.00
$153.00
$170.00
$144.00
5740
RELINE MAXILLARY PARTIAL DENTURE (CHAIRSIDE)
$104.00
$117.00
$124.00
$138.00
$145.00
$160.00
$134.00
5741
RELINE MANDIBULAR PARTIAL DENT (CHAIRSIDE)
$104.00
$117.00
$124.00
$138.00
$145.00
$160.00
$134.00
5750
RELINE COMPLETE MAXILLARY DENTURE (LAB)
$143.00
$161.00
$171.00
$190.00
$200.00
$220.00
$193.00
5751
RELINE COMPLETE MANDIBULAR DENTURE (LAB)
$143.00
$161.00
$171.00
$190.00
$200.00
$220.00
$191.00
PROSTHODONTICS (FIXED)
ADA CODE
BENEFIT DESCRIPTION
Plan 501
Plan 502
Plan 503
Plan 504
Plan 505
Plan 506
Plan 507
6240
PONTIC-PORCELAIN FUSED TO HIGH NOBLE METAL
$356.00
$399.00
$425.00
$466.00
$539.00
$563.00
$474.00
6241
PONTIC-PORCELAIN FUSED TO PREDOM BASE METAL
$328.00
$371.00
$393.00
$429.00
$451.00
$520.00
$442.00
6242
PONTIC-PORCELAIN FUSED TO NOBLE METAL
$343.00
$388.00
$412.00
$449.00
$491.00
$538.00
$457.00
6750
CROWN-PORCELAIN FUSED TO HIGH NOBLE METAL
$392.00
$443.00
$465.00
$485.00
$515.00
$600.00
$490.00
6751
CROWN-PORCELAIN FUSED TO PREDOM BASE METAL
$353.00
$399.00
$423.00
$450.00
$479.00
$565.00
$442.00
6752
CROWN-PORCELAIN FUSED TO NOBLE METAL
$367.00
$414.00
$440.00
$468.00
$490.00
$587.00
$458.00
ORAL SURGERY
ADA CODE
BENEFIT DESCRIPTION
Plan 501
Plan 502
Plan 503
Plan 504
Plan 505
Plan 506
Plan 507
7140
EXTRACTION,ERUPTED TOOTH OR EXPOSED ROOT
$44.00
$49.00
$53.00
$59.00
$61.00
$70.00
$59.00
7220
REMOVAL OF IMPACTED TOOTH-SOFT TISSUE
$90.00
$101.00
$108.00
$120.00
$125.00
$144.00
$130.00
7230
REMOVAL OF IMPACTED TOOTH-PARTIALLY BONY
$117.00
$132.00
$140.00
$156.00
$164.00
$187.00
$165.00
7240
REMOVAL OF IMPACTED TOOTH-COMPLETELY BONY
$170.00
$185.00
$197.00
$203.00
$219.00
$245.00
$204.00
7250
SURGICAL REMOVAL OF RESIDUAL TOOTH ROOTS
$90.00
$102.00
$102.00
$108.00
$115.00
$135.00
$120.00
7310
ALVEOLOPLASTY IN CONJUNCTION WITH EXTRACTION PER QUAD
$75.00
$84.00
$90.00
$99.00
$105.00
$120.00
$118.00
7320
ALVEOLOPLASTY NOT IN CONJUNCTION WITH EXTRACTION PER QUAD
$108.00
$122.00
$130.00
$144.00
$152.00
$173.00
$166.00
7510
INCISION/DRAINAGE OF ABSCESS-INTRAORAL SOFT TISSUE
$55.00
$62.00
$67.00
$74.00
$77.00
$89.00
$78.00
ORTHODONTICS
ADA CODE
BENEFIT DESCRIPTION
Plan 501
Plan 502
Plan 503
Plan 504
Plan 505
Plan 506
Plan 507
8070
COMPLETE ORTHODONTIC TREATMENT-TRANSITIONAL DENTITION
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
8080
COMPLETE ORTHODONTIC TREATMENT-ADOLESCENT DENTITION
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
8090
COMPLETE ORHTODONTIC TREATMENT-ADULT DENTITION
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
MISCELLANEOUS SERVICES
ADA CODE
BENEFIT DESCRIPTION
Plan 501
Plan 502
Plan 503
Plan 504
Plan 505
Plan 506
Plan 507
9110
PALLIATIVE TREATMENT DENTAL PAIN-MINOR PROCEDURE
$29.00
$32.00
$35.00
$38.00
$40.00
$46.00
$42.00
9215
LOCAL ANESTHESIA
$10.00
$12.00
$13.00
$14.00
$15.00
$18.00
$18.00
9230
ANALGESIA
$21.00
$22.00
$23.00
$25.00
$25.00
$30.00
$25.00
9951
OCCLUSAL ADJUSTMENT LIMITED
$40.00
$46.00
$48.00
$54.00
$56.00
$64.00
$65.00
9952
OCCLUSAL ADJUSTMENT COMPLETE
$162.00
$183.00
$194.00
$216.00
$227.00
$260.00
$265.00
table end
Table with 4 columns and 15 rows
*This schedule applies to services provided by a participating CAREINGTON General Dentist. The purpose of this schedule is to establish the maximum fee
that a General Dentist will charge for each procedure. Member is responsible for all charges at the time of service. Participating Specialists (Board Certified
or Advanced Degree) do not charge according to a fee schedule. Participating Specialists will give up to a 20% discount off of their normal fees. Fee schedules
are subject to change without prior notification to members.
*It is the Member’s responsibility to verify that the dentist is a participating Provider before seeking any treatment. Any dental procedures performed
by a non-participating dentist are not discounted and are charged at the dentist's normal fees.
*The dollar amount specified adjacent to each procedure may not be the only cost incurred for a given treatment - many treatments may require more than
one dental procedure. Please consult your CAREINGTON provider for a detailed treatment plan prior to beginning any work.
*Procedures not listed on this schedule will be discounted at 20% of the General Dentist's normal fee.
*Implants and some whitening procedures will not be discounted by all participating CAREINGTON providers. Implants and some whitening procedures will only
be discounted if the participating CAREINGTON provider has agreed to discount these procedures as part of their contract. These services will be offered,
when applicable, at a 15% discount off of the provider's normal fee. Please call 800-290-0523 for assistance.
*If the General Dentist's normal fee for any procedure is less than the fee listed on this schedule, the dentist will charge 20% off of their normal fee
for that procedure.
*Work in progress prior to enrollment on the dental plan must be completed by the dentist who started the work and is subject to no discount.
*CAREINGTON can not guarantee the continued participation of any dentist. If the dentist leaves the plan, you will need to select another participating
CAREINGTON provider. Not all types of dentists may be available in your area.
*Any procedure involving lab fees will incur additional costs. All applicable lab fees are the responsibility of the member.
*While all participating CAREINGTON providers are professionally licensed in the state in which they practice, CAREINGTON does not guarantee the quality
of service of the providers. Any quality of care concerns involving any participating CAREINGTON provider should be directed in writing to: CAREINGTON
International, Attn. Provider Relations, PO Box 2568, Frisco, Texas 75034. Please call 406-695-2225 if you have any further questions.
table end
Plan 501
AL
FL
GA
IL
KS
KY
LA
MN
MO
MS
NE
OH
OK
PA
TN
TX
VA
Plan 502
AZ
CO
IN
MD
MI
Plan 503
AR
HI
MA
ND
NJ
SD
WV
Plan 504
DC
IA
NC
NY
SC
Plan 505
CT
ID
ME
MT
OR
UT
VT
WI
WY
Plan 506
AK
DE
NH
RI
Plan 507
CA
Diagnostic and Preventive Services
ADA CODE
BENEFIT DESCRIPTION
Plan 501
Plan 502
Plan 503
Plan 504
Plan 505
Plan 506
Plan 507
0120
PERIODIC ORAL EVALUATION
$12.00
$13.00
$14.00
$15.00
$16.00
$18.00
$19.00
0140
LIMITED ORAL EVALUATION-PROBLEM FOCUS
$14.00
$16.00
$16.00
$18.00
$20.00
$22.00
$28.00
0150
COMPREHENSIVE ORAL EVALUATION-NEW OR ESTABLISHED PATIENT
$14.00
$16.00
$16.00
$18.00
$20.00
$22.00
$32.00
0210
X-RAYS-INTRAORAL-COMPLETE SERIES (INCLUDING BITEWINGS)
$35.00
$39.00
$41.00
$46.00
$48.00
$55.00
$55.00
0220
X-RAYS-INTRAORAL-PERIAPICAL-1ST FILM
$8.00
$9.00
$9.00
$10.00
$11.00
$13.00
$11.00
0230
X-RAYS-INTRAORAL-PERIAPICAL-EACH ADDITIONAL FILM
$4.00
$5.00
$5.00
$5.00
$5.00
$6.00
$8.00
0270
BITEWING X-RAY-SINGLE FILM
$8.00
$9.00
$9.00
$10.00
$12.00
$13.00
$10.00
0272
BITEWINGS-TWO FILMS
$10.00
$12.00
$13.00
$14.00
$15.00
$16.00
$15.00
0274
BITEWINGS-FOUR FILMS
$17.00
$20.00
$21.00
$23.00
$24.00
$28.00
$22.00
0330
PANORAMIC FILM
$35.00
$39.00
$41.00
$46.00
$48.00
$55.00
$47.00
1110
PROPHYLAXIS-ADULT CLEANING
$25.00
$29.00
$30.00
$33.00
$36.00
$40.00
$37.00
1120
PROPHYLAXIS-CHILD CLEANING
$18.00
$21.00
$25.00
$28.00
$29.00
$33.00
$28.00
1201
TOPICAL APPLICATION OF FLUORIDE (INCLUDING PROPHYLAXIS)-CHILD
$23.00
$29.00
$35.00
$37.00
$40.00
$45.00
$38.00
1351
SEALANT-PER TOOTH
$17.00
$20.00
$21.00
$22.00
$23.00
$28.00
$22.00
1510
SPACE MAINTAINER-FIXED-UNILATERAL
$75.00
$84.00
$90.00
$99.00
$105.00
$120.00
$138.00
1515
SPACE MAINTAINER-FIXED-BILATERAL
$110.00
$124.00
$132.00
$147.00
$154.00
$177.00
$196.00
1520
SPACE MAINTAINER-REMOVEABLE-UNILATERAL
$98.00
$110.00
$117.00
$130.00
$137.00
$156.00
$164.00
1525
SPACE MAINTAINER-REMOVEABLE-BILATERAL
$124.00
$140.00
$150.00
$166.00
$174.00
$199.00
$205.00
RESTORATIVE
ADA CODE
BENEFIT DESCRIPTION
Plan 501
Plan 502
Plan 503
Plan 504
Plan 505
Plan 506
Plan 507
2140
AMALGAM-ONE SURFACE, PRIMARY OR PERMANENT
$35.00
$39.00
$41.00
$46.00
$48.00
$55.00
$46.00
2150
AMALGAM-TWO SURFACES, PRIMARY OR PERMANENT
$44.00
$49.00
$53.00
$59.00
$61.00
$70.00
$61.00
2160
AMALGAM-THREE SURFACES, PRIMARY OR PERMANENT
$52.00
$59.00
$62.00
$69.00
$72.00
$83.00
$73.00
2161
AMALGAM-FOUR OR MORE SURFACES, PRIMARY OR PERMANENT
$63.00
$71.00
$76.00
$84.00
$89.00
$101.00
$90.00
2330
RESIN-BASED COMPOSITE-ONE SURFACE, ANTERIOR
$44.00
$49.00
$53.00
$59.00
$61.00
$70.00
$57.00
2331
RESIN-BASED COMPOSITE-TWO SURFACES, ANTERIOR
$53.00
$60.00
$63.00
$70.00
$74.00
$85.00
$72.00
2332
RESIN-BASED COMPOSITE-THREE SURFACES, ANTERIOR
$67.00
$76.00
$81.00
$89.00
$93.00
$107.00
$93.00
2335
RESIN-BASED COMPOSITE-FOUR OR MORE SURFACES, ANTERIOR
$84.00
$94.00
$101.00
$112.00
$117.00
$135.00
$115.00
2391
RESIN-BASED COMPOSITE-ONE SURFACE, POSTERIOR
$55.00
$65.00
$69.00
$74.00
$81.00
$90.00
$64.00
2392
RESIN-BASED COMPOSITE-TWO SURFACES, POSTERIOR
$82.00
$95.00
$99.00
$107.00
$115.00
$131.00
$90.00
2393
RESIN-BASED COMPOSITE-THREE SURFACES, POSTERIOR
$103.00
$117.00
$125.00
$138.00
$153.00
$166.00
$115.00
2394
RESIN-BASED COMPOSITE-FOUR OR MORE SURFACES, POSTERIOR
$119.00
$134.00
$144.00
$159.00
$176.00
$190.00
$136.00
2750
CROWN-PORCELAIN FUSED TO HIGH NOBLE METAL
$409.00
$463.00
$495.00
$515.00
$550.00
$615.00
$491.00
2751
CROWN-PORCELAIN FUSED TO PREDOMINANTLY BASE METAL
$371.00
$420.00
$450.00
$469.00
$496.00
$600.00
$440.00
2752
CROWN-PORCELAIN FUSED TO NOBLE METAL
$387.00
$437.00
$483.00
$500.00
$525.00
$608.00
$460.00
2790
CROWN-FULL CAST HIGH NOBLE METAL
$403.00
$456.00
$484.00
$505.00
$530.00
$628.00
$475.00
2791
CROWN-FULL CAST PREDOMINANTLY BASE METAL
$361.00
$425.00
$450.00
$475.00
$505.00
$595.00
$415.00
2930
PREFABRICATED STAINLESS STEEL CROWN-PRIMARY
$81.00
$91.00
$97.00
$107.00
$113.00
$123.00
$111.00
2931
PREFABRICATED STAINLESS STEEL CROWN-PERMANENT
$92.00
$104.00
$110.00
$122.00
$129.00
$138.00
$128.00
2950
CORE BUILDUP-INCLUDING ANY PINS
$81.00
$91.00
$97.00
$107.00
$113.00
$120.00
$112.00
2951
PIN RETENTION PER TOOTH IN ADDITION TO RESTORATION
$20.00
$22.00
$23.00
$24.00
$26.00
$30.00
$24.00
2952
CAST POST AND CORE IN ADDITION TO CROWN
$127.00
$143.00
$152.00
$168.00
$177.00
$199.00
$175.00
2954
PREFABRICATED POST AND CORE IN ADDITION TO CROWN
$99.00
$112.00
$118.00
$131.00
$138.00
$150.00
$138.00
ENDODONTICS
ADA CODE
BENEFIT DESCRIPTION
Plan 501
Plan 502
Plan 503
Plan 504
Plan 505
Plan 506
Plan 507
3110
PULP CAP DIRECT (EXCLUDING FINAL RESTORATION)
$18.00
$20.00
$22.00
$24.00
$25.00
$30.00
$29.00
3120
PULP CAP INDIRECT (EXCLUDING FINAL RESTORATION)
$18.00
$20.00
$22.00
$24.00
$25.00
$28.00
$29.00
3220
THERAPEUTIC PULPOTOMY (EXCLUDING FINAL RESTORATION)
$44.00
$49.00
$53.00
$59.00
$61.00
$70.00
$70.00
3310
ROOT CANAL-ANTERIOR (EXCLUDING FINAL RESTORATION)
$236.00
$267.00
$283.00
$294.00
$330.00
$377.00
$280.00
3320
ROOT CANAL-BICUSPID (EXCLUDING FINAL RESTORATION)
$279.00
$316.00
$336.00
$352.00
$391.00
$447.00
$336.00
3330
ROOT CANAL-MOLAR (EXCLUDING FINAL RESTORATION)
$351.00
$397.00
$421.00
$447.00
$491.00
$561.00
$423.00
PERIODONTICS
ADA CODE
BENEFIT DESCRIPTION
Plan 501
Plan 502
Plan 503
Plan 504
Plan 505
Plan 506
Plan 507
4210
GINGIVECTOMY OR GINGIVOPLASTY-FOUR OR MORE CONTIGUOUS TEETH OR BONDED TEETH SPACES PER QUADRANT
$235.00
$271.00
$282.00
$310.00
$330.00
$389.00
$265.00
4341
PERIODONTAL SCALING AND ROOT PLANING-FOUR OR MORE CONTIGUOUS TEETH OR BONDED TEETH SPACES PER QUADRANT
$82.00
$90.00
$100.00
$102.00
$110.00
$127.00
$98.00
4910
PERIODONTAL MAINTENANCE (FOLLOWING ACTIVE THERAPY)
$52.00
$55.00
$60.00
$65.00
$70.00
$79.00
$57.00
PROSTHODONTICS (REMOVABLE)
ADA CODE
BENEFIT DESCRIPTION
Plan 501
Plan 502
Plan 503
Plan 504
Plan 505
Plan 506
Plan 507
5110
COMPLETE DENTURE-MAXILLARY
$515.00
$582.00
$619.00
$662.00
$715.00
$815.00
$632.00
5120
COMPLETE DENTURE-MANDIBULAR
$515.00
$582.00
$619.00
$662.00
$715.00
$815.00
$632.00
5130
IMMEDIATE DENTURE-MAXILLARY
$536.00
$606.00
$643.00
$713.00
$760.00
$858.00
$665.00
5140
IMMEDIATE DENTURE-MANDIBULAR
$536.00
$606.00
$643.00
$713.00
$760.00
$858.00
$670.00
5211
MAXILLARY PARTIAL DENTURE-RESIN BASE (INCLUDING ANY CONVENTIONAL CLASPS, RESTS AND TEETH)
$505.00
$530.00
$605.00
$649.00
$701.00
$801.00
$474.00
5212
MANDIBULAR PARTIAL DENTURE-RESIN BASE (INCLUDING ANY CONVENTIONAL CLASPS, RESTS AND TEETH)
$505.00
$530.00
$605.00
$649.00
$701.00
$801.00
$474.00
5213
MAXILLARY PARTIAL DENTURE-CAST METAL FRAMEWORK WITH RESIN DENTURE BASES (INCLUDING ANY CONVENTIONAL CLASPS, RESTS OR TEETH)
$584.00
$660.00
$702.00
$755.00
$798.00
$915.00
$680.00
5214
MANDIBULAR PARTIAL DENTURE-CAST METAL FRAMEWORK WITH RESIN DENTURE BASES (INCLUDING ANY CONVENTIONAL CLASPS, RESTS, AND TEETH)
$584.00
$660.00
$702.00
$755.00
$798.00
$915.00
$683.00
5410
ADJUST COMPLETE DENTURE-MAXILLARY
$29.00
$30.00
$35.00
$36.00
$38.00
$43.00
$34.00
5411
ADJUST COMPLETE DENTURE-MANDIBULAR
$29.00
$30.00
$35.00
$36.00
$38.00
$43.00
$34.00
5510
REPAIR BROKEN COMPLETE DENTURE BASE
$46.00
$52.00
$55.00
$61.00
$64.00
$74.00
$76.00
5520
REPLACE MISSING OR BROKEN TEETH
$44.00
$49.00
$53.00
$59.00
$61.00
$70.00
$69.00
5630
REPAIR OR REPLACE BROKEN CLASP
$53.00
$60.00
$63.00
$70.00
$74.00
$85.00
$98.00
5650
ADD TOOTH TO EXISTING PARTIAL DENTURE
$46.00
$52.00
$55.00
$61.00
$64.00
$74.00
$84.00
5660
ADD CLASP TO EXISTING PARTIAL DENTURE
$59.00
$67.00
$70.00
$78.00
$82.00
$94.00
$103.00
5730
RELINE COMPLETE MAXILLARY DENTURE (CHAIRSIDE)
$109.00
$123.00
$131.00
$145.00
$153.00
$170.00
$144.00
5731
RELINE COMPLETE MANDIBULAR DENTURE (CHAIRSIDE)
$109.00
$123.00
$131.00
$145.00
$153.00
$170.00
$144.00
5740
RELINE MAXILLARY PARTIAL DENTURE (CHAIRSIDE)
$104.00
$117.00
$124.00
$138.00
$145.00
$160.00
$134.00
5741
RELINE MANDIBULAR PARTIAL DENT (CHAIRSIDE)
$104.00
$117.00
$124.00
$138.00
$145.00
$160.00
$134.00
5750
RELINE COMPLETE MAXILLARY DENTURE (LAB)
$143.00
$161.00
$171.00
$190.00
$200.00
$220.00
$193.00
5751
RELINE COMPLETE MANDIBULAR DENTURE (LAB)
$143.00
$161.00
$171.00
$190.00
$200.00
$220.00
$191.00
PROSTHODONTICS (FIXED)
ADA CODE
BENEFIT DESCRIPTION
Plan 501
Plan 502
Plan 503
Plan 504
Plan 505
Plan 506
Plan 507
6240
PONTIC-PORCELAIN FUSED TO HIGH NOBLE METAL
$356.00
$399.00
$425.00
$466.00
$539.00
$563.00
$474.00
6241
PONTIC-PORCELAIN FUSED TO PREDOM BASE METAL
$328.00
$371.00
$393.00
$429.00
$451.00
$520.00
$442.00
6242
PONTIC-PORCELAIN FUSED TO NOBLE METAL
$343.00
$388.00
$412.00
$449.00
$491.00
$538.00
$457.00
6750
CROWN-PORCELAIN FUSED TO HIGH NOBLE METAL
$392.00
$443.00
$465.00
$485.00
$515.00
$600.00
$490.00
6751
CROWN-PORCELAIN FUSED TO PREDOM BASE METAL
$353.00
$399.00
$423.00
$450.00
$479.00
$565.00
$442.00
6752
CROWN-PORCELAIN FUSED TO NOBLE METAL
$367.00
$414.00
$440.00
$468.00
$490.00
$587.00
$458.00
ORAL SURGERY
ADA CODE
BENEFIT DESCRIPTION
Plan 501
Plan 502
Plan 503
Plan 504
Plan 505
Plan 506
Plan 507
7140
EXTRACTION,ERUPTED TOOTH OR EXPOSED ROOT
$44.00
$49.00
$53.00
$59.00
$61.00
$70.00
$59.00
7220
REMOVAL OF IMPACTED TOOTH-SOFT TISSUE
$90.00
$101.00
$108.00
$120.00
$125.00
$144.00
$130.00
7230
REMOVAL OF IMPACTED TOOTH-PARTIALLY BONY
$117.00
$132.00
$140.00
$156.00
$164.00
$187.00
$165.00
7240
REMOVAL OF IMPACTED TOOTH-COMPLETELY BONY
$170.00
$185.00
$197.00
$203.00
$219.00
$245.00
$204.00
7250
SURGICAL REMOVAL OF RESIDUAL TOOTH ROOTS
$90.00
$102.00
$102.00
$108.00
$115.00
$135.00
$120.00
7310
ALVEOLOPLASTY IN CONJUNCTION WITH EXTRACTION PER QUAD
$75.00
$84.00
$90.00
$99.00
$105.00
$120.00
$118.00
7320
ALVEOLOPLASTY NOT IN CONJUNCTION WITH EXTRACTION PER QUAD
$108.00
$122.00
$130.00
$144.00
$152.00
$173.00
$166.00
7510
INCISION/DRAINAGE OF ABSCESS-INTRAORAL SOFT TISSUE
$55.00
$62.00
$67.00
$74.00
$77.00
$89.00
$78.00
ORTHODONTICS
ADA CODE
BENEFIT DESCRIPTION
Plan 501
Plan 502
Plan 503
Plan 504
Plan 505
Plan 506
Plan 507
8070
COMPLETE ORTHODONTIC TREATMENT-TRANSITIONAL DENTITION
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
8080
COMPLETE ORTHODONTIC TREATMENT-ADOLESCENT DENTITION
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
8090
COMPLETE ORHTODONTIC TREATMENT-ADULT DENTITION
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
20% Discount
MISCELLANEOUS SERVICES
ADA CODE
BENEFIT DESCRIPTION
Plan 501
Plan 502
Plan 503
Plan 504
Plan 505
Plan 506
Plan 507
9110
PALLIATIVE TREATMENT DENTAL PAIN-MINOR PROCEDURE
$29.00
$32.00
$35.00
$38.00
$40.00
$46.00
$42.00
9215
LOCAL ANESTHESIA
$10.00
$12.00
$13.00
$14.00
$15.00
$18.00
$18.00
9230
ANALGESIA
$21.00
$22.00
$23.00
$25.00
$25.00
$30.00
$25.00
9951
OCCLUSAL ADJUSTMENT LIMITED
$40.00
$46.00
$48.00
$54.00
$56.00
$64.00
$65.00
9952
OCCLUSAL ADJUSTMENT COMPLETE
$162.00
$183.00
$194.00
$216.00
$227.00
$260.00
$265.00
table end
Table with 4 columns and 15 rows
*This schedule applies to services provided by a participating CAREINGTON General Dentist. The purpose of this schedule is to establish the maximum fee
that a General Dentist will charge for each procedure. Member is responsible for all charges at the time of service. Participating Specialists (Board Certified
or Advanced Degree) do not charge according to a fee schedule. Participating Specialists will give up to a 20% discount off of their normal fees. Fee schedules
are subject to change without prior notification to members.
*It is the Member’s responsibility to verify that the dentist is a participating Provider before seeking any treatment. Any dental procedures performed
by a non-participating dentist are not discounted and are charged at the dentist's normal fees.
*The dollar amount specified adjacent to each procedure may not be the only cost incurred for a given treatment - many treatments may require more than
one dental procedure. Please consult your CAREINGTON provider for a detailed treatment plan prior to beginning any work.
*Procedures not listed on this schedule will be discounted at 20% of the General Dentist's normal fee.
*Implants and some whitening procedures will not be discounted by all participating CAREINGTON providers. Implants and some whitening procedures will only
be discounted if the participating CAREINGTON provider has agreed to discount these procedures as part of their contract. These services will be offered,
when applicable, at a 15% discount off of the provider's normal fee. Please call 800-290-0523 for assistance.
*If the General Dentist's normal fee for any procedure is less than the fee listed on this schedule, the dentist will charge 20% off of their normal fee
for that procedure.
*Work in progress prior to enrollment on the dental plan must be completed by the dentist who started the work and is subject to no discount.
*CAREINGTON can not guarantee the continued participation of any dentist. If the dentist leaves the plan, you will need to select another participating
CAREINGTON provider. Not all types of dentists may be available in your area.
*Any procedure involving lab fees will incur additional costs. All applicable lab fees are the responsibility of the member.
*While all participating CAREINGTON providers are professionally licensed in the state in which they practice, CAREINGTON does not guarantee the quality
of service of the providers. Any quality of care concerns involving any participating CAREINGTON provider should be directed in writing to: CAREINGTON
International, Attn. Provider Relations, PO Box 2568, Frisco, Texas 75034. Please call 406-695-2225 if you have any further questions.
table end
ASI Dental Fee Schedule
NHCD Dental Fee Schedule
Use this fee schedule if NHCD appears in the PLAN column on the provider list
**Note - Colorado & Georgia do NOT follow this fee schedule. Customers in CO & GA must contact their local NHCD office.**
**For Colorado please call 1-303-427-2220 - For Georgia please call 1-770-452-9610**
Table with 3 columns and 5 rows
NHCD Fee Schedule for General Dentists
Prices effective July 1, 2004
Procedure
Member Pays
Oral Exam
Office Visit
Bitewing X-ray
Fluoride Treatment - Child (1/year)
Home Care Prevention
Cleaning, Child or Adult
Pulp Vitality Tests
Infection Control
}
$25.00
Total Charge
(Once per Year)
(Dental office may require full mouth X-rays on initial visit of new patients. Usual charge $80.00 - Member's Charge $35.00
table end
Diagnostic and Preventative Services
Infection Control
$10.00
0120 Periodic Oral Evaluation
$16.00
0150 Comprehensive Oral Evaluation
$16.00
0210 Full Mouth X-rays
$38.00
0220 Single Mouth X-ray
$7.00
0230 Each Additional Film
$5.00
0270 Bitewing - single film
$8.00
0272 Bitewing - two films
$10.00
0274 Bitewing - four films
$17.00
0330 Panoramic Film
$35.00
1110 Prophylaxis - Adult Cleaning
$35.00
1120 Prophylaxis - Child Cleaning
$25.00
1203-1204 Fluoride Treatment
$13.00
1351 Sealant - per tooth
$16.00
Restorative
Amalgam Fillings
2140 Primary/Permanent 1 surface
$46.00
2150 2 surfaces
$62.00
2160 3 surfaces
$76.00
2161 4 surfaces
$95.00
Resin-Based Composite
2330 Anterior 1 surface
$46.00
2331 2 surfaces
$65.00
2332 3 surfaces
$90.00
2335 4 surfaces
$119.00
2391 Posterior 1 surface
$60.00
2392 2 surfaces
$85.00
2393 3 surfaces
$120.00
2394 4 or more surfaces
$135.00
Crowns
2750 Porcelain fused high noble metal
$460.00
2751 Porcelain fused to predominantly base metal
$415.00
2752 Porcelain fused to noble metal
$425.00
2790 Full cast high noble metal
$420.00
2791 Full cast - predominantly base metal
$400.00
2930 Prefab stainless steel - primary
$85.00
2931 Prefab stainless steel - permanent
$95.00
2950 Core buildup including any pins
$110.00
2951 Pin retention/tooth in addition to crown
$20.00
2952 Cast Post and core in addition to crown
$135.00
2954 Prefab post and core in addition to crown
$105.00
Periodontics: (Gum Disease)
4211 Gingivectomy (per quad)
$169.00
4341 Scaling & Root Planing (per quad)
$100.00
4355 Full Mouth debridement
$89.00
4910 Periodontal maintenance -following active therapy
$45.00
Endodontics: (Root Canals)
(EXCLUDING FINAL RESTORATION)
3110 Pulp cap-direct
$20.00
3120 Pulp cap-indirect
$20.00
3220 Therapeutic Pulpotomy (Excluding Final Restoration)
$45.00
3310 Root canal Anterior (Excluding Final Restoration)
$270.00
3320 Root canal Bicuspid (Excluding Final Restoration)
$310.00
3330 Root canal Molar (Excluding Final Restoration)
$390.00
Prosthetics: (Dentures & Partials)
5110 Complete Upper Denture
$430.00
5120 Complete Lower Denture
$430.00
5130 Immediate Upper Denture
$465.00
5140 Immediate Lower Denture
$465.00
5213-14 Cast Metal Framework w/Resin Denture Bases
$550.00
(Including any Conventional Clasps, Rests or Teeth)
5410-11 Adjust Complete Denture
$28.00
5520 Replace missing or broken tooth
$43.00
5650 Add Tooth to Existing Partial Denture
$47.00
5560 Add Clasp to Existing Partial Denture
$60.00
5730-41 Reline Complete or Partial Denture (Chairside)
$115.00
5750-61 Reline Complete or Partial Denture (Laboratory)
$165.00
Oral Surgery
7140 Single Tooth Extraction
$50.00
(Erupted Tooth or Exposed Root)
Orthodontics: (Braces)
$3,000.00
(X-rays, study models, tracing, records, and extractions are not included)
* All of the above charges are reduces fees for services performed by a participating GENERAL DENTIST.
Procedures not listed on this schedule will be discounted at 20% of the General Dentists normal fee..
Payment is required at the time of service.
Fees do not include lab costs. Lab fees are to be paid directly to the dental office by the member.
Fees Subject to change periodically without notification.
*****SPECIALISTS*****
Any treatment provided by a participating SPECIALIST if available, in Oral Surgery, Orthodontists, Periodontics, Pedodontics, or Endodontics will be charged
at a 20-25% reduction of the Specialists fees for that particular case.
Use this fee schedule if NHCD appears in the PLAN column on the provider list
**Note - Colorado & Georgia do NOT follow this fee schedule. Customers in CO & GA must contact their local NHCD office.**
**For Colorado please call 1-303-427-2220 - For Georgia please call 1-770-452-9610**
Table with 3 columns and 5 rows
NHCD Fee Schedule for General Dentists
Prices effective July 1, 2004
Procedure
Member Pays
Oral Exam
Office Visit
Bitewing X-ray
Fluoride Treatment - Child (1/year)
Home Care Prevention
Cleaning, Child or Adult
Pulp Vitality Tests
Infection Control
}
$25.00
Total Charge
(Once per Year)
(Dental office may require full mouth X-rays on initial visit of new patients. Usual charge $80.00 - Member's Charge $35.00
table end
Diagnostic and Preventative Services
Infection Control
$10.00
0120 Periodic Oral Evaluation
$16.00
0150 Comprehensive Oral Evaluation
$16.00
0210 Full Mouth X-rays
$38.00
0220 Single Mouth X-ray
$7.00
0230 Each Additional Film
$5.00
0270 Bitewing - single film
$8.00
0272 Bitewing - two films
$10.00
0274 Bitewing - four films
$17.00
0330 Panoramic Film
$35.00
1110 Prophylaxis - Adult Cleaning
$35.00
1120 Prophylaxis - Child Cleaning
$25.00
1203-1204 Fluoride Treatment
$13.00
1351 Sealant - per tooth
$16.00
Restorative
Amalgam Fillings
2140 Primary/Permanent 1 surface
$46.00
2150 2 surfaces
$62.00
2160 3 surfaces
$76.00
2161 4 surfaces
$95.00
Resin-Based Composite
2330 Anterior 1 surface
$46.00
2331 2 surfaces
$65.00
2332 3 surfaces
$90.00
2335 4 surfaces
$119.00
2391 Posterior 1 surface
$60.00
2392 2 surfaces
$85.00
2393 3 surfaces
$120.00
2394 4 or more surfaces
$135.00
Crowns
2750 Porcelain fused high noble metal
$460.00
2751 Porcelain fused to predominantly base metal
$415.00
2752 Porcelain fused to noble metal
$425.00
2790 Full cast high noble metal
$420.00
2791 Full cast - predominantly base metal
$400.00
2930 Prefab stainless steel - primary
$85.00
2931 Prefab stainless steel - permanent
$95.00
2950 Core buildup including any pins
$110.00
2951 Pin retention/tooth in addition to crown
$20.00
2952 Cast Post and core in addition to crown
$135.00
2954 Prefab post and core in addition to crown
$105.00
Periodontics: (Gum Disease)
4211 Gingivectomy (per quad)
$169.00
4341 Scaling & Root Planing (per quad)
$100.00
4355 Full Mouth debridement
$89.00
4910 Periodontal maintenance -following active therapy
$45.00
Endodontics: (Root Canals)
(EXCLUDING FINAL RESTORATION)
3110 Pulp cap-direct
$20.00
3120 Pulp cap-indirect
$20.00
3220 Therapeutic Pulpotomy (Excluding Final Restoration)
$45.00
3310 Root canal Anterior (Excluding Final Restoration)
$270.00
3320 Root canal Bicuspid (Excluding Final Restoration)
$310.00
3330 Root canal Molar (Excluding Final Restoration)
$390.00
Prosthetics: (Dentures & Partials)
5110 Complete Upper Denture
$430.00
5120 Complete Lower Denture
$430.00
5130 Immediate Upper Denture
$465.00
5140 Immediate Lower Denture
$465.00
5213-14 Cast Metal Framework w/Resin Denture Bases
$550.00
(Including any Conventional Clasps, Rests or Teeth)
5410-11 Adjust Complete Denture
$28.00
5520 Replace missing or broken tooth
$43.00
5650 Add Tooth to Existing Partial Denture
$47.00
5560 Add Clasp to Existing Partial Denture
$60.00
5730-41 Reline Complete or Partial Denture (Chairside)
$115.00
5750-61 Reline Complete or Partial Denture (Laboratory)
$165.00
Oral Surgery
7140 Single Tooth Extraction
$50.00
(Erupted Tooth or Exposed Root)
Orthodontics: (Braces)
$3,000.00
(X-rays, study models, tracing, records, and extractions are not included)
* All of the above charges are reduces fees for services performed by a participating GENERAL DENTIST.
Procedures not listed on this schedule will be discounted at 20% of the General Dentists normal fee..
Payment is required at the time of service.
Fees do not include lab costs. Lab fees are to be paid directly to the dental office by the member.
Fees Subject to change periodically without notification.
*****SPECIALISTS*****
Any treatment provided by a participating SPECIALIST if available, in Oral Surgery, Orthodontists, Periodontics, Pedodontics, or Endodontics will be charged
at a 20-25% reduction of the Specialists fees for that particular case.
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