Download 100% of allowed covered charge. One per tooth every

JOHN DEERE EMPLOYEE BENEFITS - 2011 HEALTHCARE BENEFIT SUMMARY
Plan #2189
Benefit
Annual Deductible
Calendar Year Maximum
Orthodontic Lifetime Maximum
Preventive and Diagnostic
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Examination & routine cleanings
X-rays
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Sealants (Teeth 2, 3, 14, 15, 18, 19,
30, 31)
Fluoride treatments
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UHC International Dental
1-888-JDEERE1
None
$1,400 per individual
$1,500 per individual
100% of allowed covered charge. Two per calendar year.
100% of allowed covered charge. Bitewings twice per calendar year. Panoramic/full
mouth every 36 months.
100% of allowed covered charge. One per tooth every three years – Limited to certain
teeth – Up to age 17
100% of allowed covered charge.
All subject to calendar year maximum.
Basic/Restorative
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Fillings
Space maintainers
Non-surgical periodontal procedures
Injection of non-anesthetic medication
Occlusal adjustment
Occlusal guards
Authorized general anesthesia
Application of desensitizing
medications
Extractions – simple
Crowns/inlays (repair/re-cement
crowns and inlays)
Root canal/pulp caps
Scaling, curettage, maintenance
cleaning following perio surgery
- four times first year
- two times annually, thereafter if
needed in place of prophylaxis
Repair, recement, adjust denture/
bridgework and reline dentures
Guided tissue regeneration
Laboratory tests related to oral
surgery
100% of allowed covered charge*
100% of allowed covered charge*
100% of allowed covered charge*
100% of allowed covered charge*
100% of allowed covered charge*
100% of allowed covered charge*
100% of allowed covered charge*
100% of allowed covered charge*
100% of allowed covered charge*
100% of allowed covered charge*
100% of allowed covered charge*
100% of allowed covered charge*
100% of allowed covered charge*
100% of allowed covered charge*
100% of allowed covered charge*
All subject to calendar year maximum.
Prosthodontics (limit one every
five years)
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Dentures – full or partial, over
dentures
Bridgework
Precision attachments
Prosthodontic devices
100% of allowed covered charge*
100% of allowed covered charge*
100% of allowed covered charge*
100% of allowed covered charge*
All subject to calendar year maximum.
Orthodontics
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Orthodontic exams/consultation
Extractions for orthodontic reasons
Orthodontic work-up
Orthodontic treatment
100% of allowed covered charge*
100% of allowed covered charge*
100% of allowed covered charge*
100% of allowed covered charge*
All subject to orthodontics lifetime maximum.
Benefit
*Allowed charge means, in order, reasonable and customary charges, and billed charges. Reasonable and customary applies to all services.
This is a summary only.
SAP2189_11.doc
9/16/2010
Page 1
JOHN DEERE EMPLOYEE BENEFITS - 2011 HEALTHCARE BENEFIT SUMMARY
Oral Surgery (Partial List)
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100% of allowed covered charge*
Apicoectomy
100% of allowed covered charge*
General anesthesia associated with
removal of impacted tooth/teeth
 Removal of impactions
100% of allowed covered charge*
100% of allowed covered charge*
 Biopsies
100% of allowed covered charge*
 Alveoloplasty
100% of allowed covered charge*
 Tooth reimplantation/stabilization as
the result of an accident
100% of allowed covered charge*
 Removal of tumors, cysts, neoplasms
and bone tissue
 Treatment of fractures, foreign bodies, 100% of allowed covered charge*
sutures
Exclusions (Partial List)
Consultations (other than for orthodontics)
Implants
Bleaching
Replacement in less than 5 years of prosthetic devices including bridgework, partials, full dentures, etc.
Charges for infection control
Temporary partials
Porcelain on posterior teeth
TMJ splinting or appliances
Oral hygiene instruction
Drugs and medicines
Cosmetic procedures
Charges made by a dental laboratory
Replacement of lost or broken prosthetic or orthodontic device
Emergency exams except as the result of an accident
Deere & Company reserves the right to suspend, amend, modify, or terminate the Plan(s) in any manner at any time, including the right to modify or eliminate any costsharing between the company and participants. Changes, which can be made at any time, are made by action of the company’s board of directors, or to the extent
authorized by resolution of its board of directors, or by the Deere & Company Compensation Committee. In the event of a conflict between the language of the official
Plan Documents and this document, the language of the official Plan Documents will control.
*Allowed charge means, in order, reasonable and customary charges, and billed charges. Reasonable and customary applies to all services.
This is a summary only.
SAP2189_11.doc
9/16/2010
Page 2