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Individual Dental Exchange Summary

An option for individuals and families after previous coverage

Benefit Summary
Service	Benefit
Covered services limited to $300 per member per eligibility year. This is a benefit summary only. For a complete description of benefits, refer to your Policy. Effective November 1, 2008 through October 31, 2009*
Plan yearThe 12-month period commencing on the effective date and each 12-month period thereafter. maximum, per member	$1,000
Plan year deductible, per member	$50
Class 1: Examinations/X-rays (routine exam and bitewing X-rays once every six months); prophylaxis (cleanings once every six months); fissure sealants; fluoride	80%
Class 2: Restorative dentistry (treatment of tooth decay with amalgam, synthetic porcelain and plastic materials); space maintainers	80%
Class 3*: Oral surgery (surgical extractions and certain minor surgical procedures); endodontics and periodontics; 12-month waiting period on major services: crowns; cast restorations; dentures and bridge work (construction or repair of fixed bridges, partials and complete dentures)	50%

Eligibility Requirements

You must be an Oregon resident and live in Oregon at least six months out of the year. If you move outside of Oregon while on this plan, you will be automatically terminated the first of the month following your move.
You must have been previously enrolled in a dental plan for at least 12 (continuous) months. The prior coverage must meet a minimum level of benefit to qualify as creditable. The minimum benefit level acceptable is a $50 deductible to $1,000 maximum per year, with 80 percent coverage for Class 1 services (see table on page 3), 80 percent coverage for Class 2 services and 50 percent coverage for Class 3 services. Dental discount programs are not eligible to qualify as creditable prior coverage.
Eligible members will be offered this plan following the termination of their dental coverage. If you choose to elect COBRA dental coverage, you will be eligible for coverage once you terminate from your COBRA plan provided the above eligibility requirements are met. These are the only two opportunities you have to select this coverage. If you choose to decline coverage under the Individual Dental Exchange Plan, you forfeit your opportunity for membership and will not be eligible for future enrollment in this plan.
Eligible members have 90 days from the date coverage ended to enroll in the ODS Individual Dental Exchange Plan.
Dependents covered under the plan will be automatically eligible for this coverage. New dependents may be covered within 31 days of the qualifying event.

If a dental member and or dependent(s) drops this coverage, it cannot be reinstated.

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