Dental

Effective January 1, 2008, dental benefits are provided by Delta Dental. The Delta Dental PPO program allows you the freedom to visit any licensed dentist, including a dentist from the Delta Dental Premier network. However, there are advantages to visiting a Delta Dental PPO dentist instead of a Premier or non-Delta Dental dentist.

Benefit Summary - Benefits Effective January 1, 2011

	PPO Dentist	Non- PPO Dentist
Coinsurance:
Diagnostic and Preventive	100%	100%
Crowns and Cast Restorations	85%	70%
Prosthodontics (dentures and bridges)	60%	50%
Child Orthodontics	80%	70%
Maximums:
Per patient per calendar year	$2500	$2500
Diagnostic & Preventive exempt from maximum	Yes	Yes
Child Orthodontics, lifetime maximum.	$2500	$2500
Deductibles	None	None

Delta Dental PPO Dentist
You will usually pay the lowest amount for services when you visit a PPO dentist, as the PPO dentist has agreed to accept a reduced fee for PPO patients.
You are only charged your share at the time of treatment, and Delta Dental pays its portion directly to the dentist.
PPO dentists will complete claim forms and submit them for you.
Delta Dental Premier Dentist
Premier dentists will not balance bill above Delta Dental’s approved amount; however, your out of pocket costs may be higher with Premier dentists than with PPO dentists.
You are only charged your share at the time of treatment, and Delta Dental pays its portion directly to the dentist.
Premier dentists will complete claim forms and submit them for you.

Non-Delta Dental Dentists
You are responsible for the difference between the amount Delta Dental pays and the amount your non-Delta Dental dentist bills. You will usually have the highest out of pocket costs when you visit a non-participating dentist.
Non-Delta Dental dentists may require you to pay the entire amount of the bill in advance and wait for reimbursement.
You may have to complete and submit your own claim forms, or pay the non-participating dentist a fee to submit them for you.
If you visit a non-Delta Dental dentist, benefit payments will be mailed directly to you.

You may visit the Delta Dental website or call customer service to find a participating PPO dentist or Premier dentist.

Customer Service	800-765-6003
Address	Delta Dental of California
Street	San Francisco, CA 94105
Online Services	www.deltadentalins.com
Claims Address	P. O. Box 997330 Sacramento, CA 95899-7330

Dental Benefit

Maximum Benefit - $2,500 per person per calendar year

Diagnostic and Preventive Benefits	In PPO Network	Out of PPO Network
Oral examinations, routine cleanings, Bitewing x-rays, fluoride treatment, Sealants, specialist consultations, Emergency palliative treatment	100%	100%
Basic Benefits
Fillings, root canals, other x-rays, space Maintainers, periodontics (gum treatment), Tissue removal (biopsy), oral surgery (extractions)	85%	85%
Crowns, Other Cast Restorations
Crowns, inlays, onlays and cast restorations	85%	85%
Prosthodontics
Bridges, partial dentures, full dentures, Implants	60%	60%
Orthodontic Benefits
For dependent children to age 19	80%	80%
Orthodontic Maximum	$2, 500 lifetime

Note: Fees are based on PPO fees for in network dentists and the maximum plan allowance (MPA) for out of network dentists. Reimbursement is paid on Delta Dental contract allowances and not necessarily each dentist’s actual fee. You can be balance billed for services received for out of network dentists.

Refer to the Summary Plan Description for a complete list of benefits, limitations, and exclusions