BOR DENTAL Blue Cross and Blue Shield One Time Enrollment Participating Dentists Network

BOR DENTALBlue Cross and Blue Shield

One Time Enrollment

Participating Dentists Network http://www.usg.edu/admin/humex/benefits/dental

National Network (use of non-network providers will be subject to balance billing)

-------------------------- 24 month prior enrollment for replacement of

prosthetics Crown replacement when necessary after 5 years from

installation Surgical extraction of impacted wisdom teeth is not

covered 6 month prior enrollment for access to orthodontic

See detail exclusions pg. 14 of the BOR Indemnity Dental Book

BOR PREVENTIVE DENTAL CARENO DEDUCTIBLE - PLAN PAYS 100%

FLUORIDE TREATMENT

ORAL EXAMINATIONS

PROPHYLAXIS (Cleaning)

X-RAYS

BOR DENTAL CARE AFTER $50 DEDUCTIBLE - PLAN PAYS 80%

ANESTHESIA

EXTRACTIONS

FILLINGS

ROOT CANAL TREATMENT

BRIDGES

CROWNS

DENTURES

INLAYS/ONLAYS

ORTHODONTIC

APPLIANCES & TREATMENT

BOR ORTHODONTIC CARE AFTER $50 DEDUCTIBLE - PLAN PAYS 80%

BOR DENTALBlue Cross and Blue Shield

Lifetime Maximum

($1,000 for orthodontics)

Claim Form

Greater Out-of-Pocket Expense

Calendar Year Maximum ($1,000)

BOR DENTALCOST PER MONTH

-Single $27.24 -Employee/Child $51.74

-Employee/Spouse $54.46 -Family $87.14