Dental Plan

Your dental care benefits, administered through the Delta Dental Premier program, are designed to help pay for professional dental care for you and your family and covers dental services and supplies up to $1,000 per covered participant per calendar year and has a $1,500 lifetime maximum orthodontia benefit for eligible dependent children through age 18. A new calendar year benefit period begins each January 1.

Dental Deductible

No deductible is required for preventive care such as check ups and x-rays or for orthodontic care. For preventive care, the plan pays 100% of the covered charges.

There are, however, certain covered dental services that are subject to a combined annual deductible per calendar year of:

• $50 per individual (employee only)
• $100 per family (employee plus one and employee plus two or more).

When receiving services for basic restorative care, oral surgery for impacted and unimpacted teeth or major restorative care, the participant pays the first $50 per individual or $100 per family of the combined charges from these categories.

Any out-of-pocket costs that you incur, such as deductibles, employee paid percentage of coverage, and charges above the maximum plan allowance are the responsibility of the participant and are not applied toward the $1,000 maximum benefit provided under your dental plan.

After applicable deductible, dental coverage is provided as follows:

	Dental Service Coverage
	Preventive Care (check ups, x-rays)			100% (of covered services up to the maximum plan allowance)
	Basic Restorative Care (fillings, root canals, extractions, oral surgery)			80% (of covered services up to the maximum plan allowance) subject to deductible
	Major Restorative Care (bridges, dentures, crowns)			50% (of covered services up to the maximum plan allowance) subject to deductible
	Orthodontia Care			50% (of covered services up to the $1,500 orthodontia lifetime maximum)