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Delta Dental Classic Summary of Benefits Administered by Delta Dental Premier 100 (UCR) Delta Dental Premier 50 (UCR) 100/80/50 50/50/50 $50 No Deductible No Family Max No Deductible $1,000, $1,500 or $2,000 $1,000, $1,500 or $2,000 Diagnostic & Preventive Oral exams, x-rays, consultation, cleanings, emergency relief of pain, fluoride treatments 100% UCR 50% UCR Basic Oral Surgery: Extractions and other oral procedures Restorations: Amalgams and fillings Endodontics:Pulpal therapy and root canals (treatment for non-vital teeth) Periodontics:Treatment of the gum & bones supporting the teeth Sealants: Protective coating for posterior molar teeth 80% UCR 50% UCR Major Dental (No Waiting Period) Crowns, jackets and cast restorations Prosthodontics: Fixed bridges, partial or complete dentures, implants 50% UCR 50% UCR 50% (Group size of 10 or more) 50% (Group size of 10 or more) Delta Dental Premier (UCR) Plan Options for Groups of 5-99 Employees Annual Calendar Year Deductible per Patient (Deductible waived for Diagnostic & Preventive) Family Maximum (Deductible waived for Diagnostic & Preventive) Annual Maximum per Patient Optional Orthodontic Benefits For dependents up to age 19 (to 25 if full-time student). Lifetime maximum $1,000 per patient. NO WAITING PERIOD Participating Dental Offices In California Nationwide 23,400 161,000 23,400 161,000 Initial Rate Guarantee 12 Months 12 Months CKD-003 11/07 Delta Dental PPO Plan Options for Groups of 5-99 Employees Annual Calendar Year Deductible per Patient Family Maximum (Deductible waived for Diagnostic & Preventive) PPO PPO Non PPO $50 $50 Not Applicable Not Applicable Annual Maximum per Patient $1,000, $1,500 or $2,000 Diagnostic & Preventive Oral exams, x-rays, consultation, cleanings, emergency relief of pain, fluoride treatments 100%* 100%** of PPO approved fee Basic Oral Surgery: Extractions and other oral procedures Restorations: Amalgams and fillings Endodontics:Pulpal therapy and root canals (treatment for non-vital teeth) Periodontics:Treatment of the gum & bones supporting the teeth Sealants: Protective coating for posterior molar teeth 80%* 80%** of PPO approved fee Major Dental (No Waiting Period) Crowns, jackets and cast restorations Prosthodontics: Fixed bridges, partial or complete dentures, implants 50%* 50%** of PPO approved fee 50%* (Group size of 10 or more) 50%** of PPO approved fee (Group size of 10 or more) 12,300 86,000 N/A N/A Optional Orthodontic Benefits For dependents up to age 19 (to 25 if full-time student). Lifetime maximum $1,000 per patient. NO WAITING PERIOD Participating Dental Offices In California Nationwide Initial Rate Guarantee 12 Months - *An in network dentist agrees to charge PPO enrollees the approved PPO fee. **If an out-of-network dentist charges more than PPO approved fee, the patient is responsible for the difference. - You may choose any PPO dentist for PPO dentist benefits. For non-PPO dentist benefits, you may choose any dentist. PLEASE NOTE: For the PPO plans please refer to your Evidence of Coverage booklet or highlights of benefits regarding coverage for out-of-state employees. - Refer to Limitations and Exclusions section for services which may not be covered. DeltaCare (HMO) Plan Options for Groups of 5-99 Employees Patient CoPayment HMO 10A* HMO 11A** HMO 12A*** Diagnostic & Preventative Oral exams, x-rays, cleanings Consultations After hours office visits No Cost No Cost $20 No Cost $10 $25 No Cost $10 $25 Basic Oral Surgery: Restorations: Endodontics: Periodontics: No Cost No Cost $25 No Cost No Cost $45 $90 $50 No Cost $5 $50 No Cost $5 $55 $120 $80 $5 $8 $55 $5 $10 $85 $150 $80 Extractions (coronal remnants - deciduous tooth) Extractions (erupted tooth or exposed root) Removal of impacted tooth - soft tissue Amalgams - one surface, primary or permanent Sedative filling Root canal therapy - anterior Root canal therapy - bicuspid Gingivectomy, one to three contiguous teeth Major Dental (No Waiting Period) Crowns**** - resin with predominantly base metal - resin with noble metal - porcelain/ceramic Denture - complete upper or lower $55 $95 $195 $100 $95 $135 $240 $145 $145 $185 $295 $215 Orthodontic Benefits (does not include pre or post treatment fees) Individual Copays: Dependent children to age 19 Individual Copays: Adults & covered full-time students $1,700 $1,900 $1,700 $1,900 $1,700 $1,900 Participating Dental Offices In California 2,400 2,400 2,400 No Deductible & No Annual Maximum - *The Classic 10A plan was formerly named the Classic A22 plan. **The Classic 11A plan was formerly named the Classic A26 plan. ***The Classic 12A plan was formerly named the Classic A29 plan. ****Precious and semi-precious metals, if used, will be charged to the enrollee at the additional cost of the metal. This applies to crowns, bridges, and cast post and cores. Please note, DeltaCare plans are administered by Delta’s HMO affiliate, PMI Delta Health Plan. Due to the nature of an HMO program, please allow 2-4 weeks for appointments (with the exception of emergencies). Law firms, associations, groups with seasonal employment (groups in which the number of employees hired during the last year exceeds 20% of the average number of employees over the same year), and groups without an employer/employee relationship are not eligible for the DeltaCare programs. - Refer to Limitations and Exclusions section for services which may not be covered. Sales - LISI San Mateo 800.944.5474 Sacramento 800.573.5474 Fresno 800.449.5474 Los Angeles 800.970.5474 Orange 888.567.5597 San Diego 800.442.9846