TIERED DENTAL PLAN                                                        Enrollment Form
A multi-tiered dental fee-for-service program, where you have access to dentists under 3 scenarios.

Tier 1 At select participating schedule (A) Tier 1 general practitioners across the country, you will receive a no-charge exam* and x-rays in conjunction with a paid annual cleaning. Participating providers abide by a fee schedule of fixed payments for most procedures with no annual limits, deductibles, or co-pays.
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There are no waiting periods or pre-existing condition limitations on this plan, and all services including orthodontics are available immediately upon the effective date.
Fixed schedule procedure rate savings are 25% - 60% on dental care, as compared to the American Dental Association surveys of usual and customary fees.
Tier 2 In the event a Tier 1 provider is not available in a given area, a secondary schedule participating dentist may be available at some of the lowest rates of any national dental network.
Tier 3 In the event a Tier 1 or Tier 2 dentist is not available in your area, please call a Customer Care Consultant for assistance in accessing a Tier 3 provider where available.
*In conjunction with annual check-up prophylaxis (cleaning) provided by participating selected general practitioners of Tier 1.
Discount Medical Plans are provided by Patriot Health Florida, Inc., a discount medical plan organization. The features are not health insurance policies and are not available in all areas. The features provide discounts at certain health care providers for medical services and do not make payments directly to the providers of medical services. The member is obligated to pay for all health care services but will receive a discount from those health care providers who have contracted with Patriot Health Florida, Inc., located at 160 Eileen Way, Syosset, New York 11791. 800-292-3797. Discount medical Plans are not available in MT, ND, and VT.