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Volusia County School District Dental Program Group Number: 10-1396 ABOUT DELTAPREFERRED OPTION The DeltaPreferred Option (DPO) program allows you to: ♦ ♦ ♦ ♦ ♦ Save on out-of-pocket expense when you visit a network dental office Visit any dentist of your choice — select a different dentist for each member of your family Change dentists at any time Go to a dental specialist of your choice Receive dental care anywhere in the world _____________________________________________________________________________________________ Under the DPO program, you may visit any licensed dentist you wish. However, the greatest cost savings are achieved by visiting a DPO dentist. DELTAPREFERRED OPTION DENTISTS (DPO) NON-DPO DENTISTS* Your out-of-pocket expense will probably be less because DPO dentists have agreed to charge DPO patients reduced fees. You may be responsible for the dentist’s fees, which could be higher than those approved by Delta. Claim forms will be completed and submitted for you at no charge. You may have to complete and submit your own claim forms or pay a service fee. You may be charged only the patient share** at the time of treatment, not Delta’s portion. You may have to pay the entire amount in advance and wait for reimbursement. DELTAPREFERRED OPTION IS EASY TO USE DeltaPreferred Option (DPO) is Delta’s preferred provider program. The program provides the maximum benefit when you visit a DPO dentist. DPO dentists are Delta dentists who have agreed to charge DPO patients reduced fees. To use your DPO program, just call the dental office and verify that the dentist is a DPO dentist. For a list of dentists in your area, visit our web site at www.deltadentalins.com and click on dentist directory. Then, choose the DeltaPreferred Option (DPO/PPO) dentist’s link. Delta Dental offers you what no other dental plan can — the Delta Difference.® ♦ Delta dentists agree to charge you no more than the amount approved by Delta. ♦ A nationwide network of Delta dentists. ♦ We require professional treatment standards. Delta dentists must meet professional standards for hygiene, radiation safety and other areas of quality care. *If you do not choose to visit a DPO dentist, you may benefit by choosing a DeltaPremier dentist over a nonDelta dentist, since DeltaPremier dentists agree not to balance bill. **“Patient share” is the coinsurance, any deductible and any amount over the annual maximum. Some services may not be covered; please refer to your Evidence of Coverage. Some examples of services not covered are cosmetic dentistry, experimental procedure and services to correct congenital malformations. Sample Claim Payment Dentist Submitted Amount Delta Approved Amount Delta Allowed Amount Delta Payment (80%) Patient Payment** DPO Dentist $120.00 $75.00 $75.00 $60.00 $15.00 Non-DPO Dentist* $120.00 $120.00 $90.00 $72.00 $48.00 *If you do not choose to visit a DPO dentist, you may benefit by choosing a DeltaPremier dentist over a non-Delta dentist, since DeltaPremier dentists agree not to balance bill. **The difference between the Approved Amount and the Delta Payment. Group Number: 10-1396 PRINCIPAL BENEFITS AND COVERED SERVICES DPO Dentist Non-DPO Dentist* WHO’S COVERED Primary enrollee and spouse as well as eligible dependent children to age 25 DEDUCTIBLES $50 per person, $100 per family, per plan year. SERVICES THAT ARE NOT COVERED Although your program covers many of the most commonly needed services, some services are not covered. If you are unsure whether a particular procedure is covered or how much of it is paid for by your program, check with Delta before proceeding. The following are not covered by the program: ♦ Services for injuries or conditions covered under Workers’ Compensation or Employer’s Liability Laws BENEFITS MAXIMUM COMBINED MAXIMUM FOR ORTHODONTICS AND IMPLANTS DIAGNOSTIC AND PREVENTIVE BENEFITS** --oral examinations, cleanings, x-rays, biopsy/tissue examinations of tissue biopsy, fluoride treatment, space maintainers The maximum benefit paid per plan year is $1,000 per person. $1,000 separate lifetime maximum for orthodontics per enrollee and dependent child 80% of DPO fee schedule (no deductible applies to these services) 80% of UCR (Usual, Customary, and Reasonable) (no deductible applies to these services) 80% of DPO fee schedule 80% of UCR (Usual, Customary, and Reasonable) MAJOR BENEFITS** -- crowns, 50% of DPO fee schedule 50% of UCR (Usual, Customary, and Reasonable) 50% of DPO fee schedule (no deductible applies to these services) 50% of UCR (Usual, Customary, and Reasonable) (no deductible applies to these services) (extractions), fillings, restorations, denture repairs, sealants, endodontics (root canals), periodontics (gum treatment) jackets and cast restorations and prosthodontics (bridges, partial dentures, full dentures) Adults and Children Cosmetic surgery or dentistry or services to correct congenital malformation ♦ Experimental procedures ♦ Therapeutic drugs, premedication or pain relievers ♦ Hospital costs or extra charges for hospital treatment ♦ Anesthesia (except for general anesthesia for oral surgery) ♦ Extra-oral grafts, implants and implant removal The preceding information is not intended for use as a summary plan description nor is it designed to serve as an Evidence of Coverage for the program. BASIC BENEFITS** --oral surgery ORTHODONTIC AND IMPLANT BENEFITS** ♦ *If you do not choose to visit a DPO dentist, you may benefit by choosing a DeltaPremier dentist over a non-Delta dentist, since DeltaPremier dentists agree not to balance bill. **Please refer to your Evidence of Coverage for limitations on these benefits. Some examples of limitations on services are the number of cleanings and oral exams covered in a plan year, and time limitations on filling and crown replacements. All services are subject to plan year maximums. This program is administered by Delta Dental Insurance Company. If you have specific questions regarding benefit structure, limitations or exclusions, consult the Evidence of Coverage. Delta Dental Insurance Company P.O. Box 1809 Alpharetta, GA 30023-1809 1-800-616-3629 Access Delta Dental's National Dentist Directory on the Internet. Our Internet address is: www.deltadentalins.com DPO/UCRINS 3/06 FL Y O U C A N F E E L G O O D A B O U T YOUR CHOICE OF OPTIONS Delta Dental Insurance Company offers employees of the Volusia County School District two choices for maintaining proper dental health: DeltaCare and DeltaPreferred Option (DPO). BENEFITS COMPARISON Benefit DeltaCare* Annual Deductible NONE Annual Maximum NONE Diagnostic & Preventive Basic Care Fillings Extractions Root Canals Major Care Crowns** Bridge Pontic** Dentures Orthodontics You pay copayments according to a schedule: NO COST- up to $48 NO COST $8-$96 $90-$216 Delta Dental DPO $50 per person/$100 per family (No deductible on Diagnostic & Preventive, Orthodontics and Implants) $1,000 per person 80% of DPO Fee Schedule Out of DPO Network Usual, Reasonable, Customary: 80% of UCR 80% of DPO Fee Schedule 80% of UCR In DPO Network: 50% of DPO Fee Schedule 50% of UCR $132-$234 $234 $270-$360 $1,000 Lifetime Maximum Per Person $2,150 per child $2,350 per adult (includes start up fee) * You must use a DeltaCare Contract Dentist for treatment. ** Precious and semi-precious metals, if used, will be charged to you at the additional cost of the metal. This applies to crowns, bridges and cast post and cores. This is only a brief summary of the plan. The procedures above are subject to limitations, exclusions and governing administrative policies of the plan. The dental plan contract must be consulted to determine the exact terms and conditions of coverage.