CHURCHWIDE HEALTHCARE - Pension Fund

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Employer Paid Dental Program Dental PPO Plan - Delta Dental (employer paid) What is DeltaPremier USA? DeltaPremier USA is a carefully managed fee-for-service program administered by Delta Dental. “Fee-for-service” means that the dentist charges a fee for each service performed, then sends a claim to Delta Dental. Delta Dental then pays a certain percentage for each covered service. With DeltaPremier USA, you are likely to lower your out-of-pocket costs by going to a DeltaPremier participating dentist. That is because participating dentists agree to accept their fee or Delta Dental’s UCR fee, whichever is less, as full payment for covered services. More than 108,000 dentists throughout the United States and its territories participate in DeltaPremier USA. PPO Dentist Premier Dentist Non-Participating Dentist Plan Pays Plan Pays Plan Pays* Diagonstic & Preventive Diagnostic & Preventive Services: includes exams, cleanings, flouride & 100% 100% 100% space maintainers Emergency Palliative Treatment: to temporarily relieve pain 100% 100% 100% Sealants: to prevent decay of permanent teeth 100% 100% 100% Radiographs: x-rays 100% 100% 100% Basic Services Minor Restorative Services: fillings & crown repair 80% 80% 80% Endodontic Services: root canals 80% 80% 80% Periodontic Services: to treat gum disease 80% 80% 80% Oral Surgery Services: extractions & dental surgery 80% 80% 80% Other Basic Services: misc. services 80% 80% 80% Major Services Major Restorative Services: crowns 50% 50% 50% Relines & Repairs: bridges & dentures 50% 50% 50% Prosthodontic Services: includes bridges, implants & dentures 50% 50% 50% Orthodontic Services Orthodontic Services: includes braces 50% 50% 50% Orthodontic Age Limit up to age 19 up to age 19 up to age 19 *When you receive services from a Nonparticipating Dentist, the percentages in this column indicate the portion of Delta Dental’s Nonparticipating Dentist Fee that will be paid for those services. This Nonparticipating Dentist Fee may be less than what your dentist charges, which means that you will be responsible for the difference. PAGE 12
Employer Paid Dental Program Covered Services Oral exams (including evaluations by a specialist) are payable twice per calendar year. Prophylaxes (cleanings) are payable twice per calendar year. Fluoride treatments are payable twice per calendar year for people up to age 19. Bitewing X-rays are payable once per calendar year and full mouth X-rays (which include bitewing X-rays) are payable once in any five-year period. Sealants are only payable once per tooth per lifetime for the occlusal surface of first permanent molars up to age nine and second permanent molars up to age 14. The surface must be free from decay and restorations. Composite resin (white) restorations are Covered Services on posterior teeth. Porcelain crowns are optional treatment on posterior teeth. Deductible $50 deductible per person total per benefit year limited to a maximum deductible of $150 per family per benefit year. The deductible does not apply to diagnostic and preventive services, emergency palliative treatment, x-rays, sealants and orthodontic services. Dental Care Around the World Having Delta Dental coverage makes it easy for our enrollees to get dental care almost everywhere in the world! You can receive expert dental care when you are outside of the United States through our Passport Dental program. This program gives you access to a worldwide network of dentists and dental clinics. English-speaking 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. Implants and implant related services are payable once per tooth in any seven-year period. 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. Maximum Payment $1,200 per person total per benefit year on all services except orthodontics. $1,000 per person total per lifetime on orthodontic services. PAGE 13
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CHURCHWIDE HEALTHCARE - Pension Fund

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