PLAN 550V. Check-O-Matic Direct Deposit

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1 Dental Care CALIFORNIA No Maximum No Claim Forms No Deductible Pre-Existing Conditions Are Covered 30% to 100% Savings No Waiting Period for Major Dentistry Coverage Includes: Bridges, Dentures, Partials, Repairs, Orthodontics - Braces Adults & Children and/or Vision Care Federal & Postal Employees, Retired & TE s Western Dental Services American Marketing Administrators, Inc Calabasas Road Suite 2014 Calabasas, California Fax PLAN dentalhhmo@yahoo.com PLAN PLAN 550V 501V PAYROLL Deduction Bi-Weekly PLANS 13V- 295V Member Only $ Member & 1 dependent Member & 2 to5 dependents Member & 5+ dependents Qualified dependents spouse +kids V=viision Add Coverage for: Parents, Siblings, Over-age Children, Grandchildren, Domestic Partners Vision Participants Include: Eye Masters, Site for Sore Eyes, LensCrafters, Sears, JC Penny, Pearl Vision, Eyes First, Several Wal- Marts, Dullings Nationwide Vision, Steins OP Texas, and 1,000 s more! ALWAYS VERIFY PARTICIPATION (U.S.A. & Texas are available in separate brochures) Check-O-Matic Direct Deposit PLAN 550V PLAN 501V PLANS 13V- 295V MONTHLY BY PERSONAL DIRECT DEPOSIT ONLY Member Only Member & 1 Dependent Member & 2+ Dependents Member + 5 Dependents ANNUAL DIRECT BILL Member Only Member & 1 Dependent Member & 2+ Dependents SEMI-ANNUAL DIRECT BILL Member Only Member & 1 Dependent Member & 2+ Dependents QUARTERLY DIRECT BILL Member Only Member & 1 Dependent Member & 2+ Dependents Pay A, SA, Q direct deposit from your personal account *** ***We will subtract $1 You save postage You save time and effort Additional Members Add single Adult Premium *Family of (6) or more, add $1.00 per pay period, $26.00 per year ** Vision only premium Annual $45.00 per family available all 50 States Direct Deposit from your personal bank is available for any premium mode at $1.00 less monthly is 1/6 of Semi-Annual IRS Employees & Federal Judges (by the Dept of Treasury, may have the bi-weekly premium converted to once a month Please Include First Year Only Enrollment Fee (non-refundable): $15 Self or $20 Family

2 Just DentalCare &/or VisionCare Regardless of Medical Plan You May Have Review our Low Out of Pocket Copayments! Solve the 2 Pains in Dentistry 4 Dental HMO Plans to choose from & PPO Plus PPO Dental go to Any Dentist ask for brochure Free Standing Payroll Deduction or Direct Bill Payroll Deduction $5.00 Employee only and $7.00 Employee & Family *No Deductible * No Maximum * Pre Existing Covered * * No Waiting Major Dentistry * Lowest out of DDS! * * No Charge Cleaning * X-Rays * Office Visits * Exams * Sample of co-payments what your costs are at the Dentist; Filling No Charge * Crown $110 * Single Root Canal $60 * Double $85! Braces Orthodontics $1,350 spread out over 2 years + Plans Available with No Charge for Amalgam Fillings Eligible 1 st of the month after 2 nd payroll deduction or almost immediate coverage available!!! Paying Direct will get you on the 1 st of the month! Or pay at least a Quarterly Premium & we will back date for almost immediate coverage!!! Add * Parents - Over Age Kids Siblings Grandchildren Domestic Partners Add Family Members in Other Covered States!!! Just let us know where?! American Marketing Administrators, Inc PLAN UNION dentalhmo@yahoo.com *** See Brochure for Details. ***

3 California Dental Care & Vision Care for All Federal, Postal, Retired, & Families Who May Enroll? All residents in a state where coverage is made available. Eligible dependents include your spouse and unmarried children to age 19 or 23 if a full time student. Yes, Add Family Members & Domestic Partners It is our desire to provide our subscribers with the most flexibility. You may also purchase coverage for over-age children, parents, siblings, domestic partners, or any other individual that you have a financial responsibility for. You may do this by adding the individual Member premium for each person needing coverage. How to Enroll? 1. Complete the APPLICATION, CHOOSE a dentist, and select a PLAN. Attach a note with name and SS# for those in other states, such as children attending school. 2. Please send the Annual, Semi-Annual, Quarterly premium, or the bi-weekly payroll deduction form (your choice) plus the ENROLLMENT FEE with APPLICATION to: American Marketing Administrators Calabasas Rd, Suite 2014 Calabasas, CA Mail APPLICATION with your check/or company check made payable to: American Marketing Administrators 4. DO NOT send forms directly to your payroll or union offices. This will only delay your eligibility. 5. Payroll deduction forms will be mailed to you upon request if not included in brochure.checkomatic Monthly available. When Will I Become Eligible? The first of the month after your second payroll deduction and/or a full premium and enrollment fee is received. The first week you re covered an Information Card (ID) will be sent to you. Your card does not assure coverage. This may only be done through payment of premiums and following the Plan s requirements. Provider Network A list of Primary Care Providers is included in this brochure. Choose a Dentist, noting the DDS# on the APPLICATION. Specialists are at a higher fee and you may only use those contracted and referred by the PLAN. Always verify that the provider is currently contracted. You may change primary dental offices by telephoning by the 20 th of the month prior to the requested first of the month change date. A new information card will be mailed showing your new dental office. The new card is for you and is not needed for coverage Other Charges and the Member s Responsibility The providers are located in many areas. The member must pay the premium applicable to a given area. Co-payments must be paid directly to the assigned provider for all services rendered, including those provided at a reduced fee. Services not listed are available on a fee for service basis. The fees must be paid directly to the office where services are received. Coordination of Benefits All other coverage a Member may have will be assigned to the Primary Care Provider. Other dental benefits and coverage the Member may have will be considered as the primary coverage and will pay as if the PLAN coverage did not exist. The Member will never benefit more than 100% for having two (2) plans. All third parties will be billed. Grievance Procedure Please direct all grievances to the PLAN. Unresolved grievances will be settled by arbitration. VISION PLAN 1. Once eligible you ll be able to call for provider locations. 2. Mail Order may be used for the low price contact lenses. 3. Mail Order for brand name Non-Prescription Sunglasses. 4. Ophthalmological procedures including Exams, RK, PRK, and LASIK surgeries in select markets.

4 DO NOT OVERPAY. VERIFY CO-PAYMENTS IN ADVANCE BY ASKING YOUR DOCTOR FOR A TREATMENT PLAN SHOWING ALL CO-PAYMENTS PRIOR TO THE COMMENCEMENT OF WORK! Vision Care Four Great Plans & Locations Nationwide! Prescription Eye Wear Save 10-60% Ophthalmology Services Save 10-30% Replacement Contact Lenses Save 20-60% Non-Prescription Sunglasses Save 20-50% 1. PRESCRIPTION EYE WEAR SAVE 10-60% 3. OPHTHALMOLOGY SERVICES SAVE 10-30% Most frames, lenses, and specialty items (including tints, scratch resistant Through our ophthalmology network, vision members receive discounts on coatings and ultraviolet protection) are conveniently available. There is all medical eye exams and surgical procedures such as RK, PRK, ALK, and no limit on the number of times you and your family may use the membership LASIK through eye physicians in select markets nationwide. during the year. 2. REPLACEMENT OF CONTACT LENSES SAVE 20-60% 4. NON-PRESCTIPTION SUNGLASSES SAVE 20-50% Most major brands of soft contact lenses are obtainable through the mail order Most designer brands are also available at discount prices through the mail or administered by America s Eye Wear, including disposable, tonics, and E service including Serengeti, Vaumet, Guess, Cargoyles and many more. bifocals. Gas permeable materials are also available for those who prefer. SAVE AT THOUSANDS OF LOCATIONS NATIONWIDE! You and your family can now save hundreds of dollars each year. There is no limit on quantities and no restrictions on selections. This is not an insurance program. There are no claims to file, forms to fill out or waiting periods. Prices may change without notice. EYE EXAMS NOT COVERED though discounts apply! Use this plan along with your existing federal dental benefit plan and SAVE MONEY! To find the vision provider nearest you, simply call the vision number on your card. Regional Chains: American Vision Center, Budget Optical of America, Cohen s Optical, Dulings Optical, E.B. Brown Opticians, Eye Masters, Eyes First Vision Center, Sears Optical, Site for Sore Eyes, Steins Op Texas, Soptica Thomas Opticians, TSO, Uhlemann Optical, Value-Vision, Vision Works, Vision World, and many more!

5 ((format is different then the actual printed brochure the information is the same. Please, let know how many we may send to you? Principle Exclusions & Limitation of Benefits A. Oral Surgery requiring the setting of fractures or dislocation. B. Treatment of malignancies, cysts or neo-plasmas. C. Dispensing of drugs for treatment of oral diseases not normally supplied in a dental office. D. Services requiring treatment in a hospital. The member is responsible for all hospital expenses. E. Replacement of mislaid, broken, lost or stolen dentures, bridge work, and crowns. F. Replacement of an existing prosthodontics appliance, unless the existing appliance cannot be made serviceable. G. General Anesthesia, IV conscious sedation. H. Temporomandibular joint syndrome (TMJ). I. Treatment of harmful habits; ie: baby bottle syndrome. J. Full mouth X-rays once every two (2) years. K. Dentistry for cosmetic and/or elective services. L. Porcelain crowns on molars. M. Additional cost for precious and semi-precious metals. N. Unlisted procedures are available at Dentist s Usual & Customary Rate (UCR). O. Specialist procedures are at a substantially higher fee and must be authorized by the PLAN. P. Implantation of new teeth or experimental procedures. Q. Services for injuries or conditions covered under Workers Compensation or Employer s Liability Laws. R. Any treatment caused by accident, hospitalization or medical care. S. Service which, in the opinion of the attending dentist, are not necessary for your dental health or in which the result will not be satisfactory. Orthodontic Exclusions & Limitations A. Treatment co-payments are for 24 months of treatment. Treatment in excess of 24 months (extended treatment) is available at monthly co-payments, payable until treatment is completed (retainers are placed). B. Study models, x-rays, and extractions for Orthodontic purposes. C. Tracings and photographs. D. Treatment of a case in progress. E. Severe or mutilated malocclusion. California Dental Care & Vision Care Reimbursement Provisions Should you have an emergency situation occur in excess of 50 miles from your Provider, and you have attempted to call your PLAN Provider and the PLAN, and you cannot get to your dental facility for the necessary treatment, the PLAN will provide coverage for control of bleeding, control of infection, and relief of pain associated with dental problems up to $50 per year. A written itemized statement for these services must be presented to the PLAN for reimbursement within thirty (30) days. If it is necessary to have additional treatment, it must be done at the Panel Dentist you previously selected. This PLAN is primarily a General Dentist PLAN, but does have specialists in many areas. Renewal Provision

6 You may renew coverage at the prevailing rate for the benefits available at the time your coverage expires. Notice of any rate change will be mailed fifteen days prior to expiration. Individual Continuance of Benefits You may continue your coverage on a direct basis should your employment be changed or terminated from the group or plan by calling Pre-Existing Conditions Charges for programs of treatment, such as prosthodontics, orthodontics (braces already on your teeth), and periodontics, which were begun before the effective date of your coverage, are excluded. Termination of Benefits 1. On the expiration date. 2. Upon the date of entry into full-time military service. 3. Upon dependent attaining age 19 or prior marriage. An unmarried child who is 19 years old, but less than 23 years. 4. The PLAN reserves the right if, after reasonable efforts to establish and maintain satisfactory provider/patient relationship with any Member and are unable to do so, the rights of such Member and other members of his/her family under contract may be terminated effective the last day of the month during which termination occurs. 5. In the event that fees or premiums are delinquent, services and benefits under the PLAN shall be terminated effective on the last day of the month during which the delinquency occurred. 6. Permitting or committing fraud. In the event of termination, the PLAN shall complete any contracted procedure listed under PRINCIPAL BENEFITS AND COVERAGED. The Member is required to pay all fees and premiums. 7. By subscriber giving 30 days written notice of intention to cancel to the PLAN. 8. After the date on which termination becomes effective the Panel Dentists will complete any service in progress. Benefits shall cease upon (a) the date coverage expires if not renewed; (b) notice a satisfactory dentist/patient relationship cannot be established; or (c) a dependent attaining age 23 or prior to marriage. Financial Liability of Member By Statute, in the event the PLAN fails to pay the Professional Provider the Member shall not be liable to the Professional Provider for sums owed by the PLAN. If the PLAN FAILS TO PAY NON-CONTRACTING PROVIDERS, THE MEMBER MAY BE LIABLE TO THAT Non-Contracting Providers, the Member may be liable to that Non-Contracting Provider for cost of services. THIS BROCHURE CONSTITUTES ONLY A SUMMARY OF THE DENTAL CARE PLAN. THE DENTAL CARE PLAN CONTRACT MUST BE CONSULTED TO DETERMINE THE EXACT TERMS AND CONDITIONS OF COVERAGE. A SPECIMEN COPY OF THE AGREEMENT IS AVAILABLE ON REQUEST FOR EXAMINATION AT THE WESTERN DENTAL SERVICES, INC. ADMINISTRATIVE OFFICE.

7 COVERED SERVICES & PATIENT CO-PAYMENT SCHEDULE

8 DIAGNOSTIC & PREVENTIVE Pans * 550V 501V ENDODONTICS Plan 13 & 295* 550V 501V Full Mouth X-Rays No Charge No Charge No Charge Pulp Capping Single Film No Charge No Charge No Charge Pulpotomy Each Additional No Charge No Charge No Charge Recalcification (CaOH0) Oral Examination & Diagnosis No Charge No Charge No Charge Office Visits No Charge No Charge No Charge ROOT CANALS Routine by Primary General Dentist Regular Hour Emergency No Charge No Charge Single Root Canal Therapy After Hour Emergency Bi-Rooted Canal Therapy Broken Appointment Tri-Rooted Canal Therapy (W/Out 24 Hour Notice) - Per ½ Hour - Apicoectomy (Including Filling of Canal) Prophylaxis (One Every Six Months) only 1 NC No Charge No Charge Culturing Canal Prophylaxis/Fluoride (Up to Age 18) No Charge No Charge No Charge Additional cleaning 20 PROSTHETICS (Dentures) Routine by Primary General Dentist RESTORATIVE DENTISTRY Routine by Primary General Dentist Complete Maxillary Denture Amalgam Restorations Primary: Complete Mandibular Denture Cavities One Tooth Surface $ Partial Acrylic Upper or Lower with Cavities Two Tooth Surfaces Chrome Cobalt Alloy Clasps-Base Fee Cavities Three Tooth Surfaces Partial Lower or Upper with Chrome Cobalt Cavities Four or More Alloy Lingual or Palatal Bar & Acrylic Amalgam Restorations Permanent: Saddles Base Fee Cavities One Tooth Surface Teeth & Clasps (Extra Per Unit) Cavities Two Tooth Surfaces Simple Stress Breakers (Extra Each) Cavities Three Tooth Surfaces Removable (Unilateral Bridges) 75 Not Covered Cavities Four Tooth Surfaces Stay Plate (Base Fee, Plus $300 Sedative Base for Each Tooth & Clasp) Composite Restorations: 70% UCR Denture Adjustments No Charge One Surface (Anterior) Denture Reline (Laboratory Processed) Two Surface Fillings (Anterior) Office Reline Cold Cure/Acrylic Pin Retention Under Fillings Broken Denture Repair (No Teeth) Veneering (Per Tooth) Not Covered Not Covered Replace Tooth (Each Additional) Bonding (Per Tooth) Not Covered Not Covered ORAL SURGERY Routine by Primary General Dentist (not by specialist) CROWN AND BRIDGE (Per Unit) Routine by Primary General Dentist Simple Extraction Local Anesthetic Acrylic Crown Surgical Extraction Porcelain Crown Impactions (In Office) Soft Tissue Porcelain Fused to Metal Crown (N-P) Partial Bony Impaction Full Cast Crown (Non-Precious) Complete Bony Impaction 80%UCR ¾ Crown (Non-Precious) Local Anesthesia No Charge No Charge No Charge Stainless Steel (Primary) Nitrous Anesthesia N/A Stainless Steel (Permanent) Performed Dowel Post PERIODONTICS (Treatment of Gums)- Routine by Primary General Dentist Plastic Core or Amalgam Build Up Not Covered Emergency Treatment (Abscess, etc.) Cast Metal (Sanitary) Pontic Root Planning (Curettage) Per Quad Tru-Pontic Type Gingivectomy Per Quad (Including Porcelain Fused to Metal (Non-Precious) Post-Surgical Visits) Recementation No Charge Gingivectomy Osseous or Mucogingival Surgery Per Quad (Incl. Post Surg. Visits) Gingivectomy Per Tooth (Fewer than 6) ORTHODONTICS PLAN 550V,13, 295 PLAN 501V Full Banded/Full 24 Month Treatment (Not Including Start Up & Retention Fee)..1, , Consultation Fee (If Treatment is Not Accepted) No Charge **Plan 13 Southern California Plan 295 Northern California Santa Barbara and Bakersfield North. Plan 501V has copayments and coverage for bonding -All services listed are as performed by a general dentist, specialist -Co-payments do not include charges for precious, semi-precious, and gold. services are on a fee for service basis. -Out of area emergency is covered $50.00 per year. -Specialist fees will be substantially higher than general dentist -Plans may not decrease in any manner the benefits provided. co-payments, referrals must be to a contracted specialist. -Services at the above co-payments are by the general dentist & orthodontists. -Any procedure not listed AND not on the Exclusion List is at 80% UCR. - V means vision benefit included. *Pre-existing conditions covered with some limitations such as braces already on teeth, or you have started a root canal, in which case the dentist who started that procedure would need to complete it and we would provide service from one of our offices for the crown.

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