DFB TPA Services Dental and Vision Association Plan


 


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Pre-Paid Dental Plan sponsored by DFB TPA Services Association Legend Series – Summit Plan through DFB TPA Services Assurant Employee Benefits
The Legends Summit plan provides dental benefits with attractive prepayment fees.  To receive the benefits of this plan you will need to select a Plan Dentist for you and your family members from the list of Plan Dentists.  You may choose a different dentist for each family member.

Features of the Legends Summit Plan:

  • No deductibles
  • No claim forms
  • No annual maximum
  • Fixed copayment schedule for Plan Dentists
  • Reduced fees on Orthodontic procedures for children and adults
  • No referral required for Specialist benefits
  • Benefits for pre-existing dental conditions

Approximate Sample Copay when you use the plan:

ADA Code** Service Description*** Member Copayment
  Appointments  
  Office visit - During reguarly scheduled hours $5.00
D0120 Evaluation Periodic Oral No Charge
D0140 Focused Limited Oral Evaluation - Problem $20.00
D3320 Endodontic Bicuspid (excluding final restoration) $150.00
D2150 Amalgam - Filling two surfaces, primary or permanent $21.00
D2740 Substrate Crown - Porcelain/Ceramic $270.00


***Check copay schedule prices subject to change based on United Dental Cares fee schedule!
**Current and prior versions of the Current Dental Terminology (CDT) codes (in the ADA Code column) and descriptors (in the Service Description column) are copyrighted by the American Dental Association (ADA) and are used by permission. Current Dental Terminology © American Dental Association.

Frequently asked questions

 

Prepayment fee options
Annual Prepayment Fees

Individual

$240.00*

Individual with One (1) Dependent

$435.00*

Individual with Two (2) or more Dependent

$660.00*


Payment options: Credit Card or Automatic Monthly Bank Draft

Charges will be drafted on the 15th of each month prior to the month of benefits.
A monthly administration charge is included in the fees below.

Individual

$20.00*

Individual with One (1) Dependent

$36.25*

Individual with Two (2) or more Dependent

$55.00*

*$5 Monthly Administration and Association Fee is built into the rates


What are copayments?
Copayments are reduced fees that you pay directly to the dentist for some dental treatments. A partial list of some frequently used dental treatments is included in this site under Sample copayments. This list shows you the potential savings with Assurant Employee Benefits versus what you would pay without this Plan.

Cosmetic dentistry
Assurant Employee Benefits understands the importance of your appearance. That's why we have included cosmetic services, such as bleaching and bonding procedures, in your plan benefits.

Orthodontic benefits
The Legend Series Plan includes reduced fees on Orthodontic procedures for children and adults.  Plan Orthodontists provide reduced fees of 25% off his/her normal retail charge.  Orthodontic services are available only in areas where Assurant Employee Benefits has Plan Orthodontist(s) who provide those services.  Orthodontic treatment begun prior to your plan effective date is not eligible for this benefit.

Specialist benefits
Should the services of a specialist (oral surgeon, endodontist, orthodontist, periodontist, or pedodontist) be necessary, you may seek treatment from any Plan Specialist listed in our printed or online directory.  If an oral surgeon, orthodontist, periodontist or pedodontist provides treatment you will receive 25% off that specialist's normal retail charges.  For treatment by an endodontist you will receive 15% off that specialist's normal retail charges.  Specialist services are available only in areas where Assurant Employee Benefits has Plan Specialist(s). Please note that payment for a service performed by a Non-Plan Specialist is your responsibility.

How do I join?
Step 1: Select a dentist from the Plan Dentist Directory or online (choose the Legend Series).
Step 2: Complete the online Enrollment form.  Be sure to include the Dental Facility Number of each dentist you have selected in the appropriate area, and provide a valid email address.
Step 3: Choose your payment option. Completed Enrollment form, and enter credit card or Automatic bank draft information.
If you choose the automatic monthly bank draft, complete the Authorization Agreement included in this site under "Enrollment form," Monthly prepayment fees will thereafter be drawn automatically from your bank account.
While we accept automatic bank drafts from checking or savings accounts, we cannot accept personal checks on a monthly basis through the US Postal Service.

When will I receive a membership card?
Once your application has been processed, you will receive a membership card, the Individual Dental Service Agreement, and a complete list of copayments.  Your effective date will be provided with your membership materials through your email address. This is why the email address is required. It is an essential part of the enrollment process.

What if I need to change my dentist?
You may change dentists by simply calling Customer Service at 800-443-2995.

How do I receive care?
After your effective date, phone the dentist you selected and tell the office that you have Assurant Employee Benefits' prepaid coverage. They will schedule your appointment to see the dentist.

Who is eligible?
You, your spouse and dependent children as defined by state law.

When do I renew my dental plan?
If you select the annual prepayment method, a renewal notification and billing statement will be mailed to your home in advance of your anniversary date.  If you select the monthly bank draft method for payment, no action is required to renew your dental plan.

Limitations and exclusions

  • Any services not specifically described in the Copayment Schedule (including but not limited to any hospital or outpatient care facility cost associated with any dental service).
  • Any dental service initiated (a) before the effective date of Member’s enrollment or (b) after Member’s enrollment ends.
  • Services provided by Non-Plan Providers unless for Emergency Services for temporary pain relief (with limited benefits) as specifically provided in the EMERGENCY SERVICES Article of the Individual Dental Service Agreement.
  • Replacement of bridgework, dentures or other fixed or removable appliances unless (a) at least five years have elapsed since such appliance was provided as a Plan Benefit, or (b) during that five year period, appliance becomes unusable and cannot be made usable due to Member’s illness or an accident involving damage to the appliance while it is in use.
  • Replacement of dentures or other removable appliances due to (a) damage while not in use or (b) loss or theft.
  • Oral reconstruction using fixed bridgework or other fixed appliances if the overall treatment plan to achieve complete oral reconstruction involves the replacement of six or more teeth (whether those teeth are missing before treatment begins or are extracted as part of the overall treatment plan).
  • Implants or any related implant appliances, or surgery for the insertion of implants or any related implant appliances, whether fixed or removable.
  • Surgical removal of implants or implant appliances, or any surgical or non-surgical services to adjust, repair, replace, or treat any problem related to an existing implant or implant appliance, whether fixed or removable.
  • Restorations or splints used to increase vertical dimension, restore occlusion, or replace or stabilize tooth structure lost by attrition.
  • Orthodontic treatment involving therapy for myofunctional problems, TMJ (temporomandibular joint) dysfunctions, micrognathia, macroglossia, cleft palate or other growth and developmental abnormalities.
  • Orthodontic treatment associated with orthognathic surgery, whether the treatment precedes or follows the surgery.
  • Extractions of third molars (wisdom teeth) that are not symptomatic, whether or not the extractions follow the completion of orthodontic treatment. Examples of symptomatic conditions include decay, odontogenic cysts, chronic pericoronitis and infection.
  • Treatment of malignancies, neoplasms or cysts, including but not limited to biopsies.

Renewable at option of company

* Any Person obligated for any part of a prepayment fee in connection with an enrollment agreement may cancel such agreement within 72 hours after signing the agreement or offer to enroll through the internet portal. Cancellation occurs when written notice is given to company, its agents, or other representatives. Notice of cancellation shall be considered given when the prospective subscriber mails such notice to company.

 

*This Dental policy is underwritten with claims paid through Assurant Employee Benefits. You must enroll through DFB TPA Association in order to be eligible for these benefits. The association fee is included in the plan and billed through the payment choice when you enroll.

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