Alpine Plan
Pacific Union Dental

Alpine Plan with Orthodontic Benefits
Premium Rates

Participants	Bi-Weekly	Monthly	Quarterly
Employee Only	6.00	11.87	35.61
Employee + 1	10.00	19.62	58.86
Family	14.00	28.91	86.73

I. Orthodontic Benefits

Orthodontic services are provided as part of dental benefits provided by Pacific Union Dental, subject to the following provisions:

• There shall be a one-time surcharge of $2250.00 for a full-banded/2 year case, (Phase II treatment only), plus an additional charge of no more than:

$350.00 for start-up fees $150.00 for one set of retainers (with retention limited to 12 consecutive months, if necessary)

Member's payment schedule shall be as follows unless otherwise agreed upon between the member and the orthodontist:

$750.00 at the inception of care (the placement of bands). $150.00 per month for 10 months.

• Orthodontic treatment is available for each eligible member, spouse and dependent between ages 10 and 19. Orthodontic care for dependent children over the ages of 19 is not a covered benefit.

• Orthodontic treatment must be provided by a member of the orthodontic panel who is providing said treatment under a contract with Pacific Union Dental.

• Plan benefits cover 24 months of usual and customary Phase II orthodontic treatment.

II. LOSS OF BENEFIT/RESIDUAL OBLIGATIONS

Should a member be terminated or become ineligible for benefits, the member is subject to the following provisions:

• Availability of the orthodontic benefits described herein will cease upon loss of members eligibility and/or termination of the Group Subscriber Agreement for any reason. In the event benefits terminated while members and/or dependents have treatment in progress, the member may complete treatment by payment of the lesser of the following:

  1) The number of months remaining in treatment times $125 per month.

  2) $3000 less any copayments (including start-up fees) paid prior to termination of this benefit.

• If a termination of benefits occurs due to a termination of the Group Subscriber Agreement, the group shall reserve the right to assign members residual obligation as described in (a) above to a successor organization.  

• If member loses eligibility for 3 or more consecutive months they will be considered no longer eligible for orthodontic benefits, and (1) above would apply.  

• Dependents other than spouse lose benefits on the 19th birthday (subject to 1 a & b above).

III. ADDITIONAL CHARGES

• Treatment that extends beyond 24 months will be subject to an office visit charge, which will be the members responsibility.  

• The charge for each additional month will not exceed $125.00 per month.

IV. SERVICES NOT PROVIDED

The following are not benefits included as part of orthodontic services provided by Pacific Union Dental.

• Start-up including:
• Cephalometric x-rays*
• Tracings*
• Study models*
• Photos*
• Lost or broken appliances.
• Retreatment of orthodontic cases.
• Treatment in progress at inception of eligibility.
• Changes in treatment necessitated by accident of any kind.
• Extraction of teeth or surgical procedures performed for orthodontic purposes.
• Replacement (including bridgework) or restoration (including crowns) of teeth caused solely by the orthodontic treatment.
• Orthodontics for TMJ problems including assessment beyond that customarily provided in general practice.
• Cases involving:
• Surgical orthodontics.
• Myofunctional therapy.
• Cleft palate.
• Micrognathia.
• Macroglossia.
• Hormonal imbalances.
• Phase I orthodontic care.
• Orthodontic care prior to age ten or after the age of nineteen.
• Transfer of Orthodontic provider for any reason in the middle of treatment.
• Orthodontic cases extending beyond the 19th birthday are subject to loss of benefit residual obligation provision (refer to SECTION II LOSS OF BENEFIT/RESIDUAL OBLIGATIONS).
• Any treatment rendered by any noncontracted Orthodontic provider.

* Start-up fees subject to additional combined charge not to exceed $350.00.

Alpine Plan

(All forms are in PDF format. If you cannot
print a form, please call 1-800-221-3083
and we will be glad to mail forms to you.)

Form / Link	Purpose
Enrollment Form	To participate in the California DMHO Plan, an Enrollment Form must be completed, signed and mailed to Mass Benefits Consultants, Inc. You must choose a dentist and include his/her ID Number on the Enrollment Form.
CA Dentists	This chart lists all participating DHMO dentists. The dentists are listed by their office zip code. If you have any problems finding a dentist, please call National Pacific Dental 1-877-905-0990.
Benefit Schedule	The Benefit Schedule lists the co-payment amounts for dental services. If you have any questions regarding a co-payment amount, call National Pacific Dental 1-877-905-0990.
Direct Deposit Form	Complete this form if you want to pay by payroll deduction and your Payroll office processes the form.
Employee Express Form	Use this information if you want to pay by payroll deduction and you must start the deduction yourself through HR Links or Employee Express online.
Monthly Bank Draft	Complete and return this form with a voided check to pay your premium on a monthly basis.
Claims	There are no claim forms required for the DHMO plan. The co-payment amounts are listed in the Benefit Schedule.