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Delta Dental

Member Services Phone Number: 1-800-524-0149

Group Number: 1160-0001

Benefit Year - January 1 through December 31

www.deltadentalin.com

Summary of Dental Plan Benefits

(Teachers)

PPO Dentist Non-PPO Dentist
Covered Services Plan Pays You Pay Plan Pays You Pay
Class I Benefits
Diagnostic and Preventive Services - Used to diagnose and/or prevent dental abnormalities or disease (includes exams, cleanings and fluoride treatments) 100% 0% 100% 0%
Emergency Palliative Treatment - Used to temporarily relieve pain 100% 0% 100% 0%
Radiographs - X-rays 100% 0% 50% 50%
Class II Benefits
Oral Surgery Services - Extractions and dental surgery, including preoperative and postoperative care 60% 40% 50% 50%
Endodontic Services - Used to treat teeth with diseased or damaged nerves (for example, root canals) 60% 40% 50% 50%
Periodontic Services - Used to treat diseases of the gums and supporting structures of the teeth 60% 40% 50% 50%
Relines and Repairs - Relines and repairs to bridges and dentures 60% 40% 50% 50%
Minor Restorative Services - Used to repair teeth damaged by disease or injury (for example, fillings) 60% 40% 50% 50%
Major Restorative Services - Used when teeth can`t be restored with another filling material (for example, crowns) 60% 40% 50% 50%
Class III Benefits
Prosthodontic Services - Used to replace missing natural teeth (for example, bridges and dentures) 60% 40% 50% 50%
Class IV Benefits
Orthodontic Services (to age 19) - Used to correct malposed teeth (for example, braces) 50% 50% 50% 50%
  • Oral exams, prophylaxes (cleanings), and fluoride treatment (to age 19) are payable twice per calendar year.
  • Bitewing X-rays are payable twice per calendar year and full mouth X-rays are payable once in any three-year period.
  • Composite resin (white) restorations and porcelain crowns are not Covered Services on posterior teeth.
  • Implants and related services are Covered Services.
  • People with certain high-risk medical conditions may be eligible for additional prophylaxes (cleanings) or fluoride treatment. The patient should talk with his or her dentist about treatment.

Having Delta Dental coverage makes it easy for our enrollees to get dental care almost everywhere in the world! You can now receive expert dental care when you’re outside of the United States through our Passport Dental program. This program gives you access to the International SOS Assistance (I-SOS) worldwide network of dentists and dental clinics. English-speaking I-SOS operators are available around the clock to answer questions and help you schedule care. For more information, check our Web site or contact your benefits representative to get a copy of our Passport Dental information sheet.

Maximum Payment - $500 per person total per benefit year on Class I, Class II and Class III Benefits. Delta Dental's payment for Class IV Benefits will not exceed a lifetime maximum of $1,000 per eligible person.

Deductible - None.

Waiting Period - Employees who are eligible for dental benefits are covered on the first day of employment.

Eligible People - All full-time employees of the contractor working more than 30 hours a week and offered to those down to 17 1/2 hours a week and all individuals who are eligible for and elect Continuation Coverage pursuant to the Consolidated Omnibus Budget Reconciliation Act of 1985 if applicable.

Also eligible at your option are your legal spouse and your dependent children to the end of the calendar year in which they turn 19 and your dependent unmarried children to the end of the calendar year in which they turn 23 if a full-time student and eligible to be claimed by you as a dependent under the U.S. Internal Revenue Code during the current calendar year.

If you and your spouse are both eligible for coverage under this policy, you may be enrolled together on one application card or separately on individual application cards, but not both. Your dependent children may only be enrolled on one application card. Delta Dental will not coordinate benefits if you and your spouse are both covered under this policy. Unless this is a Section 125 plan, dependents who enroll in the dental plan are required to remain enrolled for a minimum of 12 months. Any dependent who drops the dental plan may not re-enroll at a later date. If this is a Section 125 plan, an election may be revoked or changed at any time if the change is the result of a change in family status as defined under Internal Revenue Code Section 125. The Contractor pays the cost of this plan for Subscribers only. The Subscriber pays the additional cost of dependent coverage.

Benefits will cease on the last day of the month in which the employee is terminated.

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