DENTAL SERVICE CENTER Dental and Vision Care … 2018-19 enrollment kit.pdf · CIGNA Dental Care (HMO) CIGNA Dental PPO Member Only 25.06 46.28 Member + One 49.17 77.31 Member + Family

DENTAL SERVICE CENTER Dental and Vision Care Plans Offered by Northrop Grumman Federal Credit Union

Post Office Box 3907 • Gardena, CA 90247-7599

Phone: 888·293·4903 • Fax: 310·323·7881

Welcome to the 2018-2019 Dental and Vision Care plan Enrollment Season!

Did you know you can get quality, affordable dental and vision coverage for yourself and your family, and

children can now be on your plan until age 26 with no student verification. Just enroll in any of the

options below during this annual, limited open enrollment period. When we receive your enrollment no

later than June 04, 2018, your coverage will take effect on July 1, 2018. If you have questions, call us toll-

free 1-888-293-4903 option 1.

Choose a dental care plan from CIGNA and VISION care coverage through VSP!

Maximize savings with the CIGNA Dental Care® (DHMO) plan.

Why pay more than you have to for dental care? The CIGNA DHMO plan has comprehensive coverage,

including orthodontic coverage for both children and adults. With the DHMO plan, you choose a

primary dentist from the network at enrollment. Specialty care is available with a referral approved for

payment. No deductibles, no claim forms, no annual maximums! Keep in mind, there is no out-of-

network coverage with a DHMO plan. Finding a DHMO network dentist is easy! Search online at

www.cigna.com or call for live customer service - 24/7 - at 1.800.CIGNA24 (1-800-244-6224) using

our plan ID 3214092.

Balance freedom and savings with the CIGNA Dental PPO (DPPO)!

As a DPPO customer, you may visit any licensed dentist, with no referrals required for specialty care.

Choosing a CIGNA Advantage Network dentist (or specialist) will save you money on your dental

bills because CIGNA Advantage Network dentists agree to offer discounts to CIGNA customers. In

addition, they cannot charge you more than their contracted rates for covered services. Finding an

Advantage Network dentist is easy! Search online at www.cigna.com or call for live customer service

- 24/7 - at 1.800.CIGNA24 (1-800-244-6224) using our plan ID 3214092.

Vision Service Plan (VSP) Choice Plan:

VSP is the largest vision care provider in the United States, with over 71,000 access points. Visit

www.vsp.com or call 1-800-877-7195 to locate a provider.

Inside this kit, you will find plan details, rates, payment options and enrollment forms for the Dental and

Vision Care Plan options. Be sure to read the enclosed plan materials carefully before making a decision.

When you’re ready to enroll, complete the enrollment form(s) for the coverage you want to have and use the

enclosed envelope to return your form(s) to us. You must complete separate enrollment forms to enroll for

both dental and vision coverage. You must also include separate checks for payment: each made payable to

“Dental Service Center”. You can send your first quarterly payment, or your entire annual premium

amount. We must receive your enrollment form(s) and check(s) no later than June 04, 2018 for

coverage to begin on July 1, 2018. . Please Note: If you cancel during the 1st year of enrollment there is

NO opportunity for reinstatement. If you cancel after the 1st year, there is a 2-year wait for reinstatement.

If you are requesting this kit after our initial open enrollment deadline, there are pro-rated rates and

enrollment deadlines for the time you are requesting.NO enrollment during the last quarter. Please see the

rate sheet for details.

Questions? Just call us toll-free at 1-888-293-4903, option 1.

To your good health,

DENTAL SERVICE CENTER

CIGNA Dental Care (HMO) CIGNA Dental PPO

Member Only 25.06 46.28

Member + One 49.17 77.31

Member + Family 68.56 114.94

Important Information about Selecting a CIGNA Dental Plan

Compare Plan features & Monthly Premiums!*

Cigna Dental Care (HMO) New

Patient Charge Schedule P5I0X Minimize out-of-pocket expenses!

CIGNA Dental PPO Visit any licensed dentist!

Finding a Dental Care network dentist is

easy: Call a representative at

1-800-CIGNA24 (1-800-244-6224) or use

the dental office locator at www.cigna.com

No claim forms to file

No deductibles to meet, so your coverage

starts right away.

No Annual dollar maximums, so you don’t

have to postpone any treatment.

Set copays for services

Access to a large credentialed national

network of independent dentists.

Specialty care available, with a referral

approved for payment.

Out-of-network benefits are not available

with the CIGNA Dental Care plan.

Finding an Advantage network dentist is easy: Call a representative at 1-800- CIGNA24 (1-800-244-6224) or use the

dental office locator at www.cigna.com

Save on out of pocket expenses for

treatment when you visit any provider in our

large national PPO Advantage network,

offering the deepest discounts.

Also, save on out of pocket expenses by

visiting a provider in the “Cigna DPPO

network”. These providers offer discounts

(less deep than offered by Advantage

provider), at the out-of-network benefit

level.

In-network or not, you’ll be reimbursed for

all or part of the cost for covered services

up to your annual dollar maximum, after

meeting your deductible.

Out of pocket expenses will be higher when

you visit a non-network dentist.

Most network dentist file claim forms for

members; members must file claims for out-

of-network care.

No referral necessary to see a specialist.

fast, accurate, convenient claims processing.

Monthly Rate*

*Monthly rates are for comparison only. Premiums are paid annually or

quarterly. Please refer to the Rate sheet included.

NG 3/18

http://www.cigna.com/

http://www.cigna.com/

More reasons to SMILE

CIGNA Dental Care (HMO) Sample Patient Charges P5I0X

NG 3/18

This Overview shows you a sampling of covered services and what you will pay with your CIGNA Dental Care Plan compared to what

you would pay without coverage. You will receive a complete NEW Patient Charge Schedule after your enrollment.

Key Highlights of the CIGNA Dental Care Plan

This plan offers coverage for a wide range of services at a cost savings. Coverage includes:

Preventive Care (cleanings, x-rays, and more) No Deductibles

Basic Care (fillings, basic restorative work) No dollar maximums

Major Service (bridges, crowns, root canals and more) No claim forms

No waiting periods Low co-payments

What You’ll Pay

Code Procedure Description

Current

P5I0X

Without Dental

Coverage*

D1110 Prophylaxis Cleaning – Adult (Limit 1 every 6 months) $0 $150

D0150 Comprehensive Oral Evaluation – New or Established Patient $0 $160

D1206 Topical Fluoride Application – Child (Up to 19th Birthday) (once in 6 months) $0 $75

D0210 X-Rays – Complete Series (including bitewings) (Limit 1 every 3 years) $0 $225

D1351 Sealant – Per Tooth $10 $102

D2150 Amalgam – Two Surface, Primary or Permanent $0 $300

D2330 Resin-Based Composite – One Surface, Anterior $0 $300

D2160 Amalgam – Three Surfaces, Primary or Permanent $0 $347

D2391 Resin-Based Composite – One Surface, Posterior $55 $295

D3310 Anterior Root Canal (Permanent Tooth) (Excluding Final Restoration) $80 $1167

D3330 Molar Root Canal (Permanent Tooth) (Excluding Final Restoration) $250 $1600

D8080

D8660

D8670

D8680

D8999

Comprehensive Orthodontic Treatment of the Adolescent Dentition (Banding)

Pre-Orthodontic Treatment Visit

Periodic Orthodontic Treatment Visit - Child (Up to 19th Birthday) (As Part of

Contract)-24 months of active treatment

Orthodontic Retention (Removal of Appliances, Construction and Placement of

Retainer(s))

Unspecified Orthodontic Procedure, By Report (Orthodontic Treatment Plan and

Records)

$400

$125

$1340

$275

$270

(Varies depending

on treatment)

D4341 Periodontal Scaling and Root Planning, Four or More Teeth or bounded Teeth Spacers

per quadrant (Limit 4 Quadrants per Consecutive 12 months)

$40

$350

D4910 Periodontal Maintenance Cleaning (Limit of 2 Within the First 12 Months After Active

Therapy)

$30

$200

Additional Periodontal Maintenance (beyond the 2 per calendar year) $55 $200

D7210 Surgical Removal of Erupted Tooth – Removal of Bone and/or Section of Tooth $30 $487

D7140 Extraction, Erupted Tooth or Exposed Root (Elevation and/or Forceps Removal) $5 $300

D7240 Removal of Impacted Tooth – Completely Bony $90 $795

D7241 Removal of Impacted Tooth – Completely Bony, Unusual Complications $110 $950

D5214 Lower Partial Denture –Metal (Including Clasps, Rests and Teeth) $160 $2247

D5110 Full Upper Denture $150 $2170

D5120 Full Lower Denture $150 $2150

D5730 Reline Complete Upper Denture (Chairside) (Limit 1 every 36 months) $35 $2247

D2750 Crown – Porcelain Fused to High Noble Metal $185 $1575

D6750 Crown – Porcelain Fused to High Noble Metal $185 $1500

D6240 Pontic – Porcelain Fused to High Noble Metal $185 $1500

D6010 Surgical placement of implant; Endosteal implant (Limit 1 implant per calendar year) $1025 $3054

D6060 Implant crown-Porcelain fused to Metal $530 $1950

D9220 General Anesthesia – First 30 minutes $160 $505 *Estimated cost without dental coverage are based on Connecticut General Life Insurance Company analysis on average charge for each dental procedure based on geographic

distribution of CIGNA Dental Care membership and national claims analysis, prepared in 2014. Actual charges without dental coverage may differ from your area charges or

local dentist’s fees.

Cigna Dental Benefit Summary

Dental Service Ctr/Flight Plan Financial Plan Renewal Date:7/1/2018

Insured by: Cigna Health and Life Insurance Company

This material is for informational purposes only and is designed to highlight some of the benefits available under this plan. Consult the plan documents

to determine specific terms of coverage relating to your plan. Terms include covered procedures, applicable waiting periods, exclusions and limitations.

Cigna Dental PPO

Network Options In-Network:

Cigna DPPO Advantage Network

Out-of-Network:

Non-Network

Reimbursement Levels Based on Contracted Fees Maximum Allowable Charge

Policy Year Benefits Maximum Applies to: Class I, II, III and IX expenses

$2,000

$1,500

Annual Deductible Individual

Family

$50

$150

$50

$150

Benefit Highlights Plan Pays You Pay Plan Pays You Pay

Class I: Diagnostic & Preventive Oral Exams

Cleanings: prophylaxis

X-rays: bitewing

Fluoride Application

Sealants: per tooth

Space Maintainers: non-orthodontic

100%

No Deductible

No Charge

80%

No Deductible

20%

No Deductible

Class II: Basic Restorative X-rays: full mouth

X-rays: panoramic

X-rays: periapical

Emergency Care to Relieve Pain

Restoration: fillings

Oral Surgery: simple extractions

Cleanings: periodontal maintenance

Periodontics: osseous surgery

Periodontics: periodontal scaling & root planing

Endodontics: root canal therapy

80%

After Annual

Deductible

20%

After Annual

Deductible

50%

After Annual

Deductible

50%

After Annual

Deductible

Class III: Major Restorative Anesthesia: general and IV sedation

Oral Surgery: oral surgical procedures

Oral Surgery: extractions of impacted teeth

Repairs: Bridges, Crowns and Inlays

Repairs: Dentures

Denture Relines, Rebases and Adjustments

Inlays and Onlays

Stainless Steel and Resin Crowns

Crowns, Bridges and Dentures

Prosthesis Over Implant

50%

After Annual

Deductible

50%

After Annual

Deductible

50%

After Annual

Deductible

50%

After Annual

Deductible

Class IX: Implants

50%

After Annual

Deductible

50%

After Annual

Deductible

50%

After Annual

Deductible

50%

After Annual

Deductible

Benefit Plan Provisions:

In-Network Reimbursement For services provided by a Cigna Dental PPO network dentist, Cigna Dental will reimburse the

dentist according to a Fee Schedule or Discount Schedule.

Non-Network Reimbursement For services provided by non-network dentist, Cigna Dental will reimburse according to the

Maximum Allowable Charge. The dentist may balance bill up to their usual fees.

Cross Accumulation All deductibles, plan maximums, and service specific maximums cross accumulate between in and

out of network. Benefit frequency limitations are based on the date of service and cross accumulate

between in and out of network.

Policy Year Benefits Maximum The plan will only pay for covered charges up to the yearly Benefits Maximum, when applicable.

Benefit-specific Maximums may also apply.

Annual Deductible This is the amount you must pay before the plan begins to pay for covered charges, when applicable.

Benefit-specific deductibles may also apply.

Pretreatment Review Pretreatment review is available on a voluntary basis when dental work in excess of $500 is

proposed.

Alternate Benefit Provision When more than one covered Dental Service could provide suitable treatment based on common

dental standards, Cigna HealthCare will determine the covered Dental Service on which payment

will be based and the expenses that will be included as Covered Expenses.

Oral Health Integration Program (OHIP) Cigna Dental Oral Health Integration Program offers enhanced dental coverage for customers with

the following medical conditions: diabetes, heart disease, stroke, maternity, head and neck cancer

radiation, organ transplants and chronic kidney disease. There’s no additional charge for the

program, those who qualify get reimbursed 100% of coinsurance for certain related dental

procedures. Eligible customers can also receive guidance on behavioral issues related to oral health

and discounts on prescription and non-prescription dental products. Reimbursements under this

program are not subject to the plan deductible, but will be applied to and are subject to the plan

annual maximum. Discounts on certain prescription and non-prescription dental products are

available through Cigna Home Delivery Pharmacy only, and you are required to pay the entire

discounted charge. For more information including how to enroll in this program and a complete

list of program terms and eligible medical conditions, go to www.mycigna.com or call customer

service 24/7 at 1.800.CIGNA24. Benefit Limitations:

Missing Tooth Limitation Provision For teeth missing prior to coverage with Cigna, the amount payable is 50% of the amount otherwise

payable until covered for 24 months; thereafter, considered a Class III expense.

Oral Exams 1 per 6 consecutive months

X-rays: bitewing 1 set per 12 consecutive months, limited to 4 films per set

X-rays: full mouth or panoramic 1 per 60 consecutive months

X-rays: periapical 4 per 12 consecutive months if not in conjunction with an operative procedure

X-rays: Intraoral occlusal 2 per 12 consecutive months

Cleaning: routine 1 prophylaxis (Class I) or periodontal maintenance (Class III) per 6 consecutive months

Fluoride Application 1 per 12 consecutive months for children under age 14

Sealants: per tooth 1 treatment per lifetime for children under age 14; payable on unrestored permanent bicuspid or

molar teeth only

Space Maintainers Limited to non-orthodontic treatment for children under age 14

Restoration: fillings 1 per 12 consecutive months; applies to replacement of identical surface fillings only, no

composite, white/tooth colored fillings on bicuspid or molar teeth

Inlays and Crowns

Replacement limited to 1 per 84 consecutive months. Benefits are based on the amount payable for

non-precious metals. No porcelain or white/tooth colored material on molar crowns or bridges.

Replacement must be indicated by major decay. For people under age 16, benefits for crowns and

inlays are limited to resin or stainless steel.

Stainless Steel and Resin Crowns 1 per 36 consecutive months for children under age 16

Endodontic Treatment Root canal retreatment 1 per 24 consecutive months, based on necessity

Periodontal Scaling and Root Planning 1 per quadrant per 36 consecutive months

Dentures and Partials Replacement limited to 1 per 84 consecutive months, if unserviceable and cannot be repaired

Denture Adjustments Covered if more than 12 consecutive months after installation; 1 per 12 consecutive months

Denture Repairs Covered if more than 12 consecutive months after installation

Denture Rebases and Relines Covered if more than 12 consecutive months after installation; 1 per 36 consecutive months

Prosthesis Over Implant

1 per 84 consecutive months if unserviceable and cannot be repaired. Benefits are based on the

amount payable for non-precious metals. No porcelain or white/tooth colored material on molar

crowns or bridges

Bridges

Replacement limited to 1 per 84 consecutive months, if unserviceable and cannot be repaired.

Benefits are based on the amount payable for non-precious metals. No porcelain or white/tooth

colored material on molar crowns or bridges

Model Payable only in conjunction with orthodontic workup

Benefit Exclusions: Covered Expenses will not include, and no payment will be made for the following:

Procedures and services not listed under Benefit Highlights;

Diagnostic: cone beam imaging; Preventive Services: instruction for plaque control, oral hygiene and diet;

Restorative: core buildup; labial veneers; precious or semi-precious metals for crowns, bridges, pontics and abutments; restoration of teeth which have

been damaged by erosion, attrition or abrasion;

Periodontics: bite registrations; splinting; Prosthodontics: overdentures; precision or semi-precision attachments;

Orthodontics: orthodontic treatment, myofunctional therapy;

Anesthesia: IV sedation or general anesthesia, except when medically or dentally necessary and when in conjunction with covered complex oral

surgery; Drugs: prescription drugs;

Procedures, appliances or restorations, whose main purpose is to change vertical dimension, diagnose or treat conditions of TMJ, stabilize

periodontally involved teeth, or restore occlusion;

Athletic mouth guards; Replacement of a lost or stolen appliance; Services performed primarily for cosmetic reasons; Personalization;

Services that are deemed to be medical in nature; Services and supplies received from a hospital;

Charges in excess of the Maximum Allowable Charge.

Contracted providers are not obligated to provide discounts on non-covered services and may charge their usual fees.

This document provides a summary only. It is not a contract. If there are any differences between this summary and the official plan documents, the

terms of the official plan documents will prevail.

Cigna Dental PPO plans are insured and/or administered by Cigna Health and Life Insurance Company (CHLIC) or Connecticut General Life Insurance

Company (CGLIC), with network management services provided by Cigna Dental Health, Inc. and certain of its subsidiaries. In Texas, the insured dental

plan is known as Cigna Dental Choice, and this plan uses the national Cigna DPPO network.

All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation “Cigna Home Delivery Pharmacy”

refers to Tel-Drug, Inc. and Tel-Drug of Pennsylvania, L.L.C. Policy forms (for insured dental plans) in OK: HP-POL99 (CHLIC), GM6000 ELI288 et

al (CGLIC); OR: HP-POL68; TN: HP-POL69/HC-CER2V1 et al (CHLIC). The Cigna name, logo, and other Cigna marks are owned by Cigna

Intellectual Property, Inc.

BSDXXXXX © 2017 Cigna

Get the best in eye care and eyewearwith NGC Retirees and VSP® VisionCare.Why enroll in VSP? We invest in the things you value most—the best care at the lowest out-of-pocket costs. Because we’rethe only national not-for-profit vision care company, you cantrust that we’ll always put your wellness first.

You’ll like what you see with VSP.Value and Savings. You’ll enjoy more value and the lowest out-of-pocketcosts.

High Quality Vision Care. You’ll get the best care from a VSP provider,including a WellVision Exam®—the most comprehensive exam designedto detect eye and health conditions.

Choice of Providers. The decision is yours to make—choose a VSP doctor,a participating retail chain, or any out-of-network provider.

Great Eyewear. It’s easy to find the perfect frame at a price that fits yourbudget.

Using your VSP benefit is easy.Create an account at vsp.com. Once your plan is effective, review yourbenefit information.

Find an eye care provider who’s right for you. To find a VSP provider,visit vsp.com or call 800.877.7195.

At your appointment, tell them you have VSP. There’s no ID cardnecessary. If you’d like a card as a reference, you can print one onvsp.com.

That’s it! We’ll handle the rest—there are no claim forms to complete whenyou see a VSP provider.

Choice in EyewearFrom classic styles to the latest designer frames, you’ll find hundreds ofoptions. Choose from featured frame brands like bebe®, Calvin Klein,Cole Haan, Flexon®, Lacoste, Nike, Nine West, and more1. Visit vsp.com tofind a Premier Program location that carries these brands. Prefer to shoponline? Check out all of the brands at Eyeconic.com, VSP's online eyewearstore.

Enroll in VSP today.You'll be glad you did.Contact us. 800.877.7195vsp.com

Protect your vision with VSP.

www.vsp.com

www.vsp.com

www.vsp.com

www.vsp.com

www.eyeconic.com

insuranceurl_fulllink

Your VSP Vision Benefits SummaryNGC Retirees and VSP provide you with an affordable eye care plan.

VSP Coverage Effective Date: 07/01/2018 VSP Provider Network: VSP ChoiceFrequencyCopayDescriptionBenefit

Your Coverage with a VSP Provider

Every 12 months$20WellVision Exam Focuses on your eyes and overall wellness

See frame and lenses$25Prescription Glasses

Every 24 monthsIncluded inPrescription

GlassesFrame

$150 allowance for a wide selection of frames$170 allowance for featured frame brands20% savings on the amount over your allowance$80 Costco® frame allowance

Every 12 monthsIncluded inPrescription

GlassesLenses Single vision, lined bifocal, and lined trifocal lenses

Polycarbonate lenses for dependent children

Every 12 months

$0

Lens Enhancements

Standard progressive lenses$95 - $105Premium progressive lenses$150 - $175Custom progressive lenses

Average savings of 20-25% on other lens enhancements

Every 12 monthsUp to $60Contacts (instead ofglasses)

$150 allowance for contacts; copay does not applyContact lens exam (fitting and evaluation)

As needed$20Diabetic Eyecare PlusProgram

Services related to diabetic eye disease, glaucoma and age-relatedmacular degeneration (AMD). Retinal screening for eligible memberswith diabetes. Limitations and coordination with medical coveragemay apply. Ask your VSP doctor for details.

Glasses and Sunglasses

Extra Savings

Extra $20 to spend on featured frame brands. Go to vsp.com/specialoffers for details.20% savings on additional glasses and sunglasses, including lens enhancements, from any VSP provider within 12months of your last WellVision Exam.

Retinal ScreeningNo more than a $39 copay on routine retinal screening as an enhancement to a WellVision Exam

Laser Vision CorrectionAverage 15% off the regular price or 5% off the promotional price; discounts only available from contracted facilities

Your Coverage with Out-of-Network Providers

Visit vsp.com for details, if you plan to see a provider other than a VSP network provider.

Exam .............................................................................. up to $45Frame ............................................................................ up to $70Single Vision Lenses ........................................... up to $30

Lined Bifocal Lenses ........................................... up to $50Lined Trifocal Lenses ......................................... up to $65

Progressive Lenses ............................................. up to $50Contacts .................................................................... up to $105

Coverage with a participating retail chain may be different. Once your benefit is effective, visit vsp.com for details. Coverage information is subject to change. In the event of a conflict between thisinformation and your organization’s contract with VSP, the terms of the contract will prevail. Based on applicable laws, benefits may vary by location.

Contact us. 800.877.7195 | vsp.com1Brands/Promotion subject to change.

©2014 Vision Service Plan. All rights reserved. VSP, VSP Vision care for life, WellVision Exam, and eyeconic.com are registered trademarks of Vision Service Plan. Flexon is a registered trademark of MarchonEyewear, Inc. All other company names and brands are trademarks or registered trademarks of their respective owners.

www.vsp.com

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DENTAL and VISION CARE PLAN RATES

Child must be under the age of 26 and student verification is no longer required.

Rates are payable annually by full payment or quarterly by automatic checking or savings

account deductions (ACH). Any returned Check or ACH is subject to a $20.00 fee (See

agreement below).

When quarterly automatic deductions are elected, the first quarterly payment for each

coverage plan selected must be made with a separate check (payable to the Dental Service

Center) submitted with each signed enrollment form.

To cancel coverage, written notice must be received by the Dental Service Center

no later than the 5th of the month prior to the month the coverage will terminate.

Please Note: If you cancel during the 1st year of enrollment there is NO

opportunity for reinstatement. If you cancel after the 1st year, there is a 2-year

wait for reinstatement.

CIGNA

Dental

HMO

P5I0X

No dental offices in the following states: AK, DE, HI, ID ,ME, MT, ND,

NH, NM, PR, RI, SD, VT, WV, WY

Payment Options: Quarterly Annual

Member Only $75.18 $300.72

Member + One $147.51 $590.04

Member + Family $205.68 $822.72

CIGNA

Dental

Preferred

Provider

Organization

(PPO)

Advantage Network

Available in all states. NOTE: The $50 deductible and $2,000 in-Advantage

Network or $1,500 out-of-network maximum is based on the plan year.


Member Only $138.84 $555.36

Member + One $231.92 $927.72

Member + Family $344.82 $1379.28

VSP Vision

Care Plan

Choice Plan

Available in all states.


Member Only $35.91 $143.64

Member + One $55.59 $222.36

Member + Family $80.07 $320.28

Authorization Agreement for Quarterly Automatic Checking or savings Account Deductions – By enrolling in any of the

dental or vision care plans above, I indicate the following:

I have a checking account at the financial institution named on the enclosed check and, for all debit entries, shall have

funds sufficient to pay such entries. Electronic debit entries shall be initiated by Dental Service Center to pay dental

and/or vision plan costs and other charges for the coverage plans selected and the entries shall constitute my receipt for

the transaction (s).

No payment to Dental Service Center shall be deemed to have been made unless and until Dental Service Center received

actual credit. I also understand that if corrections of the entry are necessary, it may involve an adjustment to my account.

I understand my direct electronic payment of the premium due will be debited on or about the 5th day of each

month prior to the following calendar quarter for which premium is due. (For example, the April-May-June

quarterly premium will be deducted from my account on the 5th of March.).

Dental Service Center reserves the right to refund or terminate electronic payment services. This agreement is to remain

in effect until Dental Service Center terminates it or receives written notification from the enrollee to terminate

participation in the plan and Dental Service Center has sufficient time to act upon the request.

You must

enroll for the

full plan year

through June 30, 2019

Send your

completed

enrollment

form(s) and

separate

check(s) by June 04, 2018

DENTAL PLAN APPLICATION

SELECT THE PLAN THAT’S RIGHT FOR YOU PLEASE PRINT

1. CIGNA PPO CIGNA HMO Please choose a dental office from the website

www.cigna.com or 1-800-244-6224. Dental Office Code No.__________

2. I am enrolling: Myself only Myself + One Myself + Family

LIST ONLY THE MEMBERS WHO ARE TO BE INSURED BELOW

Name: LAST FIRST Middle Initial Social Security No.: _________________________________________________________________________________________________________________________________________________ Address: _________________________________________________________________________________________________________________________________________________ City State Zip _________________________________________________________________________________________________________________________________________________

Telephone Date of Birth Male Female Spouse: LAST FIRST Middle Initial Social Security No.: _________________________________________________________________________________________________________________________________________________

Date of Birth Male Female If more children, enclose information on a separate sheet of paper. Child must be under the age of 26.

Child: LAST FIRST Middle Initial Social Security No.: _________________________________________________________________________________________________________________________________________________

Date of Birth Male Female

_________________________________________________________________________________________________________________________________________________ Child: LAST FIRST Middle Initial Social Security No: _________________________________________________________________________________________________________________________________________________




3. CHOOSE A PAYMENT OPTION – SEPARATE CHECKS REQUIRED FOR EACH ENROLLMENT FORM Annual Check – Enclosed is my annual payment made payable to: Dental Service Center Quarterly Automatic Deduction—Enclosed is my check to cover the first quarter’s premium for the option I selected above. I authorize Dental Service Center to deduct subsequent quarterly payments from my checking account referenced on the enclosed check. I have read and agree to the Authorization Agreement enclosed in this kit. I understand future deductions will be taken the 5th of each month prior to the following calendar quarter for which premiums is due. (For example the October, November, December quarterly premium will be taken on the 5th of September.) ____________________________________________________________________ __________________ Authorized Signature for Automatic Deductions Date

4. I accept the coverage/insurance benefits provided by this group dental plan and authorize the processing of my enrollment in the dental coverage as indicated on this form. I authorize any participating dental office to release dental records and billing information to CIGNA Dental Health for purposes of plan administration.

5. I understand that if I cancel this coverage, I must do so in writing and submit it by the 5th of the month prior to the effective cancellation month

date. I must wait 2 years before I can re-enroll.

6. New Enrollees may not cancel during the initial plan year. ____________________________________________________________________ ________________ Authorized Signature Date

DENTAL SERVICE CENTER

P. O. Box 3907, Gardena CA 90247-7599 Telephone (888) 293-4903

1. Original to Dental Service Center 2. Copy for your files

VISION CARE PLAN APPLICATION

SELECT THE COVERAGE TYPE THAT’S RIGHT FOR YOU PLEASE PRINT

1. I am enrolling: Myself only Myself + One Myself + Family

LIST ONLY THE MEMBERS WHO ARE TO BE INSURED BELOW

Name: LAST FIRST Middle Initial Social Security No.: _________________________________________________________________________________________________________________________________________________ Address: _________________________________________________________________________________________________________________________________________________ City State Zip _________________________________________________________________________________________________________________________________________________

Telephone Date of Birth Male Female Spouse: LAST FIRST Middle Initial Social Security No.: _________________________________________________________________________________________________________________________________________________

Date of Birth Male Female If more children, enclose information on a separate sheet of paper. Child must be under the age of 26.

Child: LAST FIRST Middle Initial Social Security No.: _________________________________________________________________________________________________________________________________________________






2. PAYMENT OPTION - SEPARATE CHECKS REQUIRED FOR EACH ENROLLMENT FORM

Annual Check – Enclosed is my annual payment made payable to: Dental Service Center Quarterly Automatic Deduction—I have enclosed a payment for the first quarter and I authorize Dental Service Center to deduct subsequent quarterly payments from my checking account referenced on the enclosed check. I have read and agree to the Authorization Agreement enclosed in this kit. I understand future deductions will be taken on the 5th of each month prior to the following calendar quarter for which premium is due. (For example October, November, December quarterly premium will be taken on the 5th of September.) ____________________________________________________________________ __________________

Authorized Signature for Automatic Deductions Date

3. I accept the coverage/insurance benefits provided by this group vision plan and authorize the processing of my enrollment in the vision plan. I authorize any participating vision office to release vision records and billing information to VSP for purposes of plan administration. 4. I understand that if I cancel this coverage, I must do so in writing and submit it by the 5th of the month prior to the effective cancellation month date. I must wait 2 years before I can re-enroll. 5. New Enrollees may not cancel during the initial plan year. ____________________________________________________________________ ________________ Authorized Signature Date

DENTAL SERVICE CENTER P. O. Box 3907, Gardena CA 90247-7599

Telephone (888) 293-4903 1. Original to Dental Service Center 2. Copy for your files

Documents

DENTAL SERVICE CENTER Dental and Vision Care … 2018-19 enrollment kit.pdf · CIGNA Dental Care (HMO) CIGNA Dental PPO Member Only 25.06 46.28 Member + One 49.17 77.31 Member + Family