Health Summary Plan Description

Dental Benefits

The dental benefits are designed to help pay a portion of your dental expenses. Delta Dental PPO is a preferred provider organization program offered by Delta Dental, the nation's largest and most experienced dental benefits carrier.

Eligibility

Plan I

Plan I Earned, Self-Pay and Senior Performer participants and their enrolled dependents are eligible for the dental benefits.

Plan II

Plan II Earned and Self-Pay participants who have a minimum of three years of Earned Eligibility and their enrolled dependents are eligible for the dental benefits.

Selecting a Dentist

There are two types of dentists in the Delta network:

  • Delta Dental PPO dentists
  • Delta Premier dentists

When you use a Delta Dental PPO dentist, your diagnostic and preventive services are covered at 100% and are not subject to the deductible. Payment is based on a pre-approved fee and the dentist will file your claims for you.

When you use a Delta Premier dentist, payment is based on a preapproved fee. These dentists will file your claim forms for you, but diagnostic and preventive services are subject to the deductible and paid at less than 100%.

To find a Delta Dental PPO or Delta Premier dentist:

  • Visit Delta's website: www.deltadentalins.com/sagph.
  • Call your dentist and ask if he or she is a Delta Dental PPO dentist or Delta Premier dentist.

Using a Non-Network Dentist

When you use a dentist outside of the available networks, or you reside outside the United States, payment is based on the Plan's Allowance or the fee the dentist actually charges, if less. If your dentist's fees exceed the Plan's Allowance, you are responsible for the difference between the Plan's payment and the dentist's actual charges. In addition, you will be responsible for your regular coinsurance and any deductible that may apply. Finally, your non-network dentist may collect payment up front and may not be willing to file a claim form for you.

Deductible

Dental benefits are payable once you satisfy a calendar year deductible. This is a separate deductible from the hospital, medical and prescription drug deductibles. The amount of the dental deductible differs for Plan I and Plan II as noted below:

  • Plan I - $75 per person/$200 per family*
  • Plan II - $100 per person/no family maximum

    * If two or more members of your family are injured in the same accident, only one deductible will be applied against all the covered dental charges incurred during any one year as a result of such accident.

Note: There is no deductible for diagnostic and preventive services when you use a Delta Dental PPO network dentist.

Maximum Benefit

The maximum amount the Plan will pay for all covered dental charges in a calendar year is:

  • Plan I - $2,500 per person
  • Plan II - $1,000 per person

There is no calendar year maximum for individuals under age 19.

Pre-Treatment Estimates

The dental program contains this optional feature which allows you to determine in advance how much the Plan will pay on extensive dental procedures before they are performed. The Plan strongly suggests that you ask your dentist to request a free pre-treatment estimate from Delta Dental on all basic and major services (see chart to the right). This will ensure that you know up front what the Plan will pay and the amount for which you will be responsible. Please refer to the section on filing a claim on page 86.

Covered Dental Charges and Limitations

Covered dental charges are the charges of a dentist or physician for the services and supplies required for dental care and treatment of any disease, defect or accidental injury, or for preventive dental care. Covered dental charges do not include any charge in excess of the charge customarily made for similar services and supplies by dentists or physicians in the locality concerned. Where alternative services or supplies are customarily available for such treatment, covered dental charges will only include the least expensive service or supply resulting in professionally adequate treatment.

Charges must be incurred and the services and supplies furnished while you or your dependent are covered. A charge is incurred as of the date the service is rendered or the supply is furnished, with the following three exceptions:

  1. With respect to fixed bridgework, crowns, inlays, onlays, or gold restorations, the charge is incurred on the first date of preparation of the tooth or teeth involved.
  2. With respect to full or partial dentures, the charge is incurred on the date the impression is taken.
  3. With respect to endodontics, the charge is incurred on the date the tooth is opened for root canal therapy.

Covered charges for both a temporary and permanent prosthesis will be limited to the charge for a permanent one.

Covered charges for a crown or gold filling will be limited to the charge for an amalgam filling unless the tooth cannot be restored with amalgam.

Covered charges for porcelain or plastic veneer crowns (tooth colored crowns) may be limited to the charge for a metal crown on certain teeth in the back of the mouth. You may want to obtain a pre-treatment estimate so you will know how much the Plan will pay. Charges for amalgam fillings, gold fillings, inlays and crowns are payable when they are necessary to restore
the structure of the tooth broken down by decay or non-accidental injury.

Implants (an artificial tooth root that a periodontist places into your jaw to hold a replacement tooth or bridge) are covered under the major services portion of the Plan's dental benefits. Additional surgical procedures, such as bone grafting or tissue regeneration, or special imaging techniques such as CT scans, that are performed in connection with the placement of the implant are not covered under the dental or medical benefits. You may want to obtain a pre-treatment estimate so you will know how much the Plan will pay.

Dental Benefits

Calendar Year Deductible:
Plan I – $75 per person / $200 per family;
Plan II – $100 per person / no family maximum.

Calendar Year Maximum:
Plan I – $2,500 per person;
Plan II – $1,000 per person.

There is no maximum for individuals under age 19.

If your eligibility changes from Plan I to Plan II during a calendar year, any charges that were applied toward your Plan I deductible or annual maximum will apply toward the Plan II deductible and annual maximum. If your eligibility changes from Plan II to Plan I during a calendar year, the reverse is also true.

Covered Services Delta Dental PPO Network Dentists Delta Premier or Non-Network Dentists

Diagnostic and Preventive Services

  • Oral examination – once every six months
  • Cleanings – two per calendar year*
  • X-rays:
    Bitewing – once every six months
    Full mouth – once every three years
    Panoramic – once every three years
  • Fluoride treatment – individuals under age 19, once per calendar year
  • Biopsy/tissue examination
  • Emergency palliative treatment
  • Consultation by a covered specialist
  • Space maintainers
  • Study models
  • Sealants – individuals under age 14, once every three years

Plan I
No deductible;
100% of dentist's fees

Plan II
No deductible;
100% of dentist's fees

Plan I
75% of Plan's Allowance after deductible

Plan II
60% of Plan's Allowance after deductible

Basic Services

  • Restorative – amalgam, silicate or composite fillings
  • Oral surgery – extractions including surgical removal of teeth
  • Endodontics – root canal therapy
  • Periodontics – treatment of gums and bones supporting teeth
  • General anesthetics or IV sedation for oral surgery and certain endodontic and periodontal procedures
  • Injectable antibiotics
  • Addition of teeth to existing denture
  • Repair and rebasing of existing dentures

Plan I
75% of dentist's fees after deductible

Plan II
60% of dentist's fees after deductible

Plan I
75% of Plan's Allowance after deductible

Plan II
60% of Plan's Allowance after deductible

Major Services

  • Restorative – gold fillings, inlays and crowns
  • Crown replacement – if crown is over three years old
  • Gold filling replacement – if filling is over five years old
  • Fixed bridges/partial or full dentures/implants – if required to replace lost natural teeth or an existing prosthesis or implant which is over five years old and cannot be made serviceable


Plan I
50% of dentist's fees after deductible

Plan II
50% of dentist's fees after deductible

Plan I
50% of Plan's Allowance after deductible

Plan II
50% of Plan's Allowance after deductible

* Individuals receiving post-periodontal surgery maintenance from a network or non-network dentist are entitled to cleanings and scalings up to four times per year.

An additional oral exam and teeth cleaning/scaling is available for women while they are pregnant.


Questions

If you need help or have any questions, you can call the Plan Office or contact Delta Dental:

www.deltadentalins.com/sagph or (800) 846-7418

Non-Covered Dental Expenses

  • Accidental injury to natural sound teeth. (This benefit is provided under the medical benefits. See page 40.)
  • Adjustments to prosthesis within six months from installation.
  • Anesthesia, other than anesthesia or IV sedation administered by a licensed dentist in connection with covered oral surgery and select endodontic and periodontal procedures.
  • Extra-oral grafts (grafting tissues from outside the mouth to oral tissue).
  • Hospital costs and any additional fee charged by the dentist for hospital treatment.
  • Occlusal guards and complete occlusal adjustment.
  • Orthodontic treatment other than for related extractions or space maintainers.
  • Procedures, restorations and appliances to increase vertical dimension or to restore occlusion.
  • Replacement of existing restorations for any purposes other than active tooth decay.
  • Services with respect to congenital or developmental malformations, or services and supplies cosmetic in nature, including but not limited to cleft palate, upper or lower jaw malformations, enamel hypoplasia (lack of development), fluorosis (discoloration of the teeth) and anodontia (congenitally missing teeth).
  • Services and supplies not recognized as generally accepted dental practice.
  • Services for restoring tooth structure lost from wear, for rebuilding or maintaining chewing surfaces due to teeth out of alignment or occlusion, or for stabilizing the teeth, including but not limited to equilibration and periodontal splinting.
  • Specialized techniques involving precision attachments, personalization or characterization.
  • Surgery or special imaging performed in connection with the placement of a dental implant.
  • Training in or supplies used for dietary counseling, oral hygiene or plaque control.
  • Temporomandibular joint syndrome (TMJ) treatment. (In certain circumstances, this benefit may be provided under the medical benefits. See page 42.)
  • Treatment by someone other than a dentist or physician, except when performed by a duly qualified technician under the direction of a dentist or physician.

Please also refer to "General Exclusions" on page 72.

Loss of Coverage

When you lose your eligibility for dental benefits, coverage will still be provided for services or supplies furnished within 90 days after coverage terminates if the charges were incurred while the individual was covered. See page 64 for an explanation of how to determine when a dental charge is incurred.