Page 1 Page 2 Page 3 Page 4 Page 5 Page 6 Page 7 Page 8 Page 9 Page 10 Page 11 Page 12 Page 13 Page 14 Page 15 Page 16 Page 17 Page 18 Page 19 Page 20 Page 21 Page 22 Page 23 Page 24 Page 25 Page 26 Page 27 Page 28 Page 29 Page 30 Page 31 Page 32 Page 33 Page 34 Page 35 Page 36 Page 37 Page 3815 Delta Dental PPO Plan Description •  Delta Dental offers fee-for-service dental benefits coupled with the cost management features of managed care. Subscribers have freedom of choice among dentists. Delta Dental has two networks of participating dentists: Delta Dental Premier® and Delta Dental PPOSM. Participating dentists complete and submit claim forms and participating dentists have agreed to accept Delta Dental’s applicable Maximum Plan Allowances, or their actual charge, whichever is less (the “Allowed Amount”), as payment in full for covered services. • The maximum benefit per person per year for services provided by PPO dentists is $1,500. •  The maximum benefit per person per year for services provided by Premier or non-participating dentists is $1,250. •  There is a separate $1,500 lifetime maximum per person for orthodontic services (covered for enrollees, spouses and dependents to the end of the month of the 26th birthday). •  Subscribers who use non-participating dentists may need to file claim forms for reimbursement. Plan payments will be based on Delta Dental’s applicable Maximum Plan Allowances, or the dentist’s actual charge, whichever is less (the “Allowed Amount”). Diagnostic & Preventive Services •  These services are covered at 100%, if applicable. Allowed Amount with no deductible includes: up to three oral exams per calendar year, up to three bitewing x-rays in a calendar year, one set of full mouth x-rays in a three- year period, up to three prophylaxes (teeth cleanings) in a calendar year, up to three fluoride treatments (to age 19) in a calendar year, sealants (to age 14, once in any 36-month period on unfilled permanent first and second molars), and space maintainers (to age 14). •  Diagnostic & Preventive Maximum Waiver: Diagnostic and Preventive care will not count against your plan year maximum. •  Enhanced Benefits for Pregnancy: Includes additional oral exam and choice of: additional cleaning, additional periodontal scaling/root planning, or additional periodontal maintenance procedure. Percentage Paid by Delta Dental, following $50 annual deductible for selected dental services (not to exceed $150 for family level coverage) Basic Restorative (“Silver” & “white” fillings) Oral Surgery (Extractions) Endodontics (Root canal therapy) Crown & Bridge Recementation Denture Repair Night Guards Injectable antibiotics Periodontics (Treatment of gum disorders) Major Restorative (Crowns, inlays, onlays) Prosthodontics (Dentures, bridges, implants) Orthodontics (No Deductible) 90% 80% 80% 80% 80% 80% 80% 60% 60% 60% 50% Refer to the plan brochure for complete list