Dental Benefits (Employees and Dependents)

The Fund provides you and your Dependents with coverage for dental and orthodontic services as outlined in the Schedule of Benefits on page 5. You must satisfy your calendar year deductible before the Fund pays its percentage of your covered dental benefits.

Delta Preferred Option USA
(Point-of-Service) Program

You can go to any licensed Dentist, but you could increase your benefits and lower your out-of-pocket costs by going to a Dentist who participates with Delta Dental. There are two levels of savings within this program. The highest level of cost savings occurs if you go to a Delta Preferred Option (DPO) Dentist. Your savings would be the result of lower out-of-pocket costs under your co-pays.

If you do not go to a DPO Dentist, savings are still possible if the Dentist participates in another Delta Dental program called Delta Premier. This second level of coverage may reduce your costs in comparison to a Dentist that does not participate with Delta Dental, but you might have to pay more than if you chose a DPO Dentist.

Dentists who participate in the DPO USA (Point-of-Service) program at either level have agreed to accept payment based on a predetermined schedule. If the Dentist’s fee is higher than the amount in the Delta Dental fee schedule, he or she cannot charge you the difference. This means you will pay only your copayment and deductible, if any, for covered services when you go to a Delta Dental participating Dentist. Participating Dentists will also complete and file claims for you.

There are more than 108,000 Delta Premier Dentists. To find the names of participating Dentists near you, call the Fund Office or visit www.deltadental.com. Please note that you remain free to visit any Dentist you choose regardless of DPO or Delta Premier membership.

Important. If you go to a Delta Dental participating Dentist, the Dentist will submit the claim form and you will only be responsible for any deductibles and copayments. If you go to a non-participating Dentist, you may be required to pay the Dentist his or her fees at the time of service, and then file a claim with Delta Dental for reimbursement under the Dental Plan.

Predetermination of Benefits

Be prepared: By requesting a Predetermination of Benefits, you can find out from Delta Dental how much the Plan will cover for your dental procedure and how much you will be required to pay.

In order to help you avoid any large, unexpected dental bills, if your Dentist expects that the course of treatment recommended will exceed $300, you should ask your Dentist to submit to Delta Dental the treatment plan that describes each procedure necessary to fully complete treatment before starting any dental work. Delta Dental will review the information to determine how much the Fund will pay.

This Predetermination of Benefits is a convenience to let you know in advance what portion of the cost of your dental treatment will be your responsibility. Delta Dental will respond directly to your Dentist with its decision as to whether or not the dental treatment will be covered and how much will be paid. The Predetermination of Benefits is also available if your Dentist is not participating in the Delta Dental Plan.

This Predetermination of Dental Benefits is not a guarantee of coverage. It is intended to let you know in advance what portion of the cost of your dental treatment will be your responsibility.

Covered Dental Services

Class I Benefits – Preventive Services

Diagnostic and Preventive Services: Services and procedures to evaluate existing conditions and/or to prevent dental abnormalities or disease. These services include examinations, prophylaxes, and fluoride treatments. Emergency Palliative Treatment: Emergency treatment to temporarily relieve pain. Radiographs: X-rays as required for routine care or as necessary for the diagnosis of a specific condition. Recement Crowns.

Class II Benefits – Basic Services

Endodontic Services: The treatment of teeth with diseased or damaged nerves (for example, root canals). Excludes apicoectomy. Minor Restorative Services: Minor services to rebuild and repair natural tooth structure when damaged by disease or Injury. Minor restorative services include amalgam (silver) and resin (white) fillings. Emergency and Specialty Exams.

Class III Benefits – Major Services

Oral Surgery Services: Extractions and dental surgery, including preoperative and postoperative care. Periodontic Services: The treatment of diseases of the gums and supporting structures of the teeth. This includes periodontal maintenance following active therapy (periodontal prophylaxes). Actisite is a covered benefit. Relines and Repairs: Relines and repairs to crowns, bridges, partial dentures, and complete dentures. Major Restorative Services: Services to rebuild and repair natural tooth structure when damaged by disease or Injury, such as crowns, used when teeth cannot be restored with another filling material. Prosthodontic Services: Services and appliances that replace missing natural teeth (such as bridges, partial dentures, and complete dentures). Veneers – Labial Veneers – (cosmetic bonding). Apicoectomy – Periradicular Surgery. Dental Anesthesia: Dental anesthesia is payable at 50%, subject to the deductible and calendar year maximum. General anesthesia/IV sedation is a covered charge only if there is demonstrated medical need, including the following: Toxicity to local anesthetic, Severe disability, spastic or severe behavioral problems, Prolonged or severe surgical procedure (includes removal of impacted tooth-soft tissue, removal of impacted tooth – partial bony, removal impacted tooth – completely bony impacted, surgical removal of residual tooth roots (cutting procedure) and surgical exposure impacted/unerupted teeth for orthodontia purposes, Extractions in two or more quadrants, Acute infection around the injection site, Failure of local anesthesia to control pain, or Subject is under four years of age.

Class IV Benefits – Orthodontic Services

Orthodontic Services (to age 19): Services, treatment, and procedures to correct malposed teeth. If your Eligible Dependent begins receiving Orthodontic services under an Orthodontic treatment plan before reaching age 19, benefits for Orthodontic services under that treatment plan will continue after your Eligible Dependent reaches age 19 until he or she no longer meets the definition of Eligible Dependent, subject to the limitations in the Schedule of Benefits on page 5.

Dental Service Limitations

Covered dental services are limited in certain cases. All charges for the following dental services will be your responsibility. All time limitations are measured from the last date of service in any Delta Dental plan record or, at the request of your group, any dental plan record:

1. Four bitewing X-rays are payable once in any calendar year. Full mouth X-rays (which include bitewing X-rays) are payable once in any three-year period. A panographic X-ray (including bitewings) is considered a full mouth X-ray.

2. Prophylaxes and oral exams are payable twice in any calendar year. Two additional periodontal prophylaxes are payable per calendar year for individuals with a documented history of periodontal disease. Preventive fluoride treatments are payable once per calendar year for Dependent Children until their 19th birthday.

3. A space maintainer is a covered benefit for patients up to the age of 16.

4. Cast restorations (including jackets, crowns, inlays and onlays) and associated procedures (such as core build-ups and post substructures) on the same tooth are payable once in any five-year period.

5. A crown, inlay, or onlay is a covered benefit only for extensive loss of tooth structure due to caries and/or fracture.

6. An individual crown over an implant is payable at the prosthodontic benefit level.

7. Porcelain, porcelain substrate, and cast restorations are not payable for Children younger than 12 years of age.

8. A stayplate is a covered benefit only for the replacement of permanent anterior teeth during the healing period or for missing anterior permanent teeth for Dependent Children 16 years or younger.

9. Prosthodontic (Class III) benefit limitations:

a) One complete upper and one complete lower denture are benefits once in any five-year period for any individual.

b) A removable partial denture or fixed bridge for any individual can be covered once in any five-year period, unless the loss of additional teeth requires the construction of a new appliance. Fixed bridges are covered only for Participants 16 years or older.

c) A reline or the complete replacement of denture base material is limited to once in any three-year period per appliance.

d) A soft reline is limited to once in any three-year period.

e) Root planing benefits are payable once per year.

10. Orthodontic (Class IV) benefit limitations:

a) Orthodontic benefits are payable until your Eligible Dependent’s 19th birthday.

b) If the treatment plan is terminated before completion of the case for any reason, the Fund’s obligation will cease with payment to the date of termination.

c) The Dentist may terminate treatment, with written notification to Delta Dental and to the patient, for lack of patient interest and cooperation. In those cases, the Fund’s obligation for payment of benefits ends on the last day of the month in which the patient was last treated.

d) An observation and adjustment is a benefit twice in a 12-month period.

e) Delta Dental will pay 50% of your initial down payment (up to $750) and then provide coverage for your treatment in quarterly installments until the rest of the Fund’s maximum benefit is reached.

f) The calendar year deductible does not apply to orthodontic benefits.

11. The Plan’s obligation for payment of benefits ends on the last day of the month in which coverage is terminated. However, the Plan will make payment for covered services provided on or before the last day of the month in which coverage is terminated, unless otherwise specified.

12. When services in progress are interrupted and completed later by another Dentist, Delta Dental will review the claim to determine the amount of payment, if any, to each Dentist.

13. Care terminated due to the death of a Participant will be paid to the limit of the Fund maximum for the services completed or in progress.

14. Optional treatment: If the Participant chooses a more expensive service than is customarily provided or for which the Plan or Delta Dental does not determine a valid dental need is shown, the Plan or Delta Dental can make an allowance based on the fee for the customarily provided service.

For example, if the Participant chooses an overdenture, the Fund will pay only the applicable amount that it would have paid for a conventional denture.

15. Maximum Payment:

a) The maximum benefit payable in any one calendar year will be limited to the amount specified in the Schedule of Benefits on page 5.

b) The payment for orthodontic (Class IV) benefits will be limited to the lifetime maximum in the Schedule of Benefits on page 5.

• The Plan and Delta Dental will not be obligated to pay for any services to which the deductible applies until the Plan deductible amount is met.
• Processing policies, such as periodic limitations on certain services, may limit treatment.

Services Not Paid by the Plan

No payment will be made by the Plan for the following services. A participating Dentist cannot charge you or your eligible Dependent for these services. All charges from non-participating Dentists for the following services will be your responsibility:

Amalgam and resin restorations are payable once within a 24-month period, regardless of the number or combination of restorations placed on a surface.

Cores and other substructures are covered benefits only when needed to retain a crown on a tooth with excessive breakdown due to caries and fractures.

Recementation of a crown, onlay, inlay, space maintainer, or bridge within six months of the seating date or within 12 months of payment for a recementation.

Retention pins are benefits once in a 24-month period. Only one substructure per tooth is a covered benefit.

Benefits for periodontal surgery, including subgingival curettage, is payable once in any three-year period.

A complete occlusal adjustment is a covered benefit once in a five-year period. The fee for a complete occlusal adjustment includes all adjustments that are necessary for a five-year period. A limited occlusal adjustment is not a covered benefit more than three times in a five-year period. The fee for a limited occlusal adjustment includes all adjustments that are necessary for a six-month period.

Tissue conditioning is not a covered benefit more than twice per arch in 36 months.

8. The allowance for a denture repair (including reline or rebase) will not exceed half the fee for a new denture.

9. More than one root planing per year.

Dental Exclusions

In addition to the General Exclusions and Limitations listed beginning on page 54, the Fund does not cover any loss under the Dental Expense Benefits caused by, incurred for or resulting from the following excluded charges. All charges for the following services will be your responsibility, although your payment obligation may be satisfied by insurance or some other arrangement for which you are eligible:

1. Services, as determined by the Fund, for correction of congenital or developmental malformations, cosmetic surgery, or dentistry for cosmetic aesthetic reasons including repair to facings posterior to the second bicuspid position.

2. Prescription drugs (except intramuscular injectable antibiotics), premedications, medicaments/solutions, and relative analgesia. Medicines or drugs that can be obtained without a Dentist’s prescription.

3. General anesthesia and/or intravenous sedation for restorative dentistry (or for surgical procedures) except as provided under Class III Benefits, item (h) on pages 39-40.

4. Acupuncture, acupressure or hypnosis.

5. Charges for hospitalization, laboratory tests and histopathological examinations.

6. Treatment performed by anyone other than a Dentist, except for services performed by a licensed Dental Hygienist under the scope of his or her license.

7. Services that are covered under the Major Medical or Prescription Drug Benefits.

8. Fluoride rinses, self-applied fluorides or desensitizing medicaments.

9. Preventive control programs (including oral hygiene instructions, caries susceptibility tests, dietary control, tobacco counseling, home care medicaments, nutritional guidance, etc.).

10 Sealants.

11. A space maintainer for maintaining space due to the premature loss of the anterior primary teeth.

12. Lost, missing, or stolen appliances of any type and replacement or repair of orthodontic appliances or space maintainers.

13. A prefabricated crown used as a final restoration on a permanent tooth.

14. Appliances, surgical procedures, and restorations for: increasing vertical dimension; altering, restoring, or maintaining occlusion; replacing tooth structure loss resulting from attrition, abrasion, or erosion; or implantology techniques or periodontal splinting, except orthodontic care for Dependent Children under age 19.

15. A substructure to a single/abutment crown over an implant.

16. A paste-type root canal filling on a permanent tooth.

17. Occlusal guards.

18. Chemical curettage.

19. Services associated with overdentures.

20. Acusil, flexiplast or similar partial denture.

21. A metal base on a removable prosthesis.

22. The replacement of teeth beyond the normal complement of teeth.

23. Personalization/characterization of any service or appliance.

24. Temporary appliances.

25. Precision attachments.

26. Implants and implant-related services.

27. Appliances, restorations or services for the diagnosis or treatment of disturbances of the temporomandibular joint dysfunction (TMJ or TMD).

28. Diagnostic photographs and cephalometric films, unless done for orthodontics.

29. Myofunctional therapy.

30. Mounted case analysis.

31. The replacement or alteration of full or partial dentures or fixed bridgework, unless the charge is required due to one of the following events and if the replacement or alteration is completed within 12 months after the event:

a) An Injury requiring surgery; or

b) Oral surgery treatment involving the repositioning of muscle attachments or the removal of a tumor, cyst, torus or redundant tissue; or

c) Replacement of a full denture, unless required as the result of structural change within the mouth and unless made more than five years after the installation of the denture.

32. Orthodontic treatment for you and your spouse.

• 33. Charges for failure to keep a scheduled visit with the Dentist.
• 34. Services, as determined by Delta Dental, for which no valid dental need can be demonstrated, that are specialized techniques, or that are experimental or investigational in nature as determined by the standards of generally accepted dental practice.
• 35. Those benefits excluded by the policies and procedures of Delta Dental including the processing policies.
• 36. Services or supplies for which no charge is made, for which you are not legally obligated to pay or for which no charge would be made in the absence of Delta Dental coverage.

37. Services or supplies received as a result of dental disease, defect or Injury due to an act of war, declared or undeclared.

38. Services that are not within the classes of benefits that have been selected and that are not in the contract.

• 39. Replacement, repair, relines or adjustments of occlusal guards.

Dental Charges Not Paid by the Fund or Delta Dental

No payment will be made by the Plan or Delta Dental for the following services. A participating Dentist cannot charge you or your Eligible Dependent for these services. All charges from non-participating Dentists for the following services will be your responsibility:

• The fee for a consultation that is part of the fee for the examination and/or diagnostic procedure(s).

2. Acid etching, cement bases, cavity liners, and a base or temporary filling.

3. Infection control.

4. Gingivectomy as an aid to the placement of a restoration.

5. The correction of occlusion, when performed with prosthetics and restorations involving occlusal surfaces.

6. Diagnostic casts not done in conjunction with orthodontics. They are considered to be a part of the fee for restorative or prosthodontic procedures.

7. Palliative treatment, when any other service is provided on the same date, except X-rays and tests necessary to diagnose the emergency condition.

8. Postoperative radiographs, when done following any completed service or procedure.

9. Periodontal charting, when done on the same day as an oral examination. An examination, when done on the same day as a periodontal prophylaxis.

10. Pins and/or a preformed post, when done with a core for a crown, onlay, or inlay.

11. A pulp cap, when done with a sedative filling or any other restoration. A sedative or temporary filling, when done with the opening and drainage of a tooth or another endodontic procedure. The opening and drainage of a tooth or palliative treatment, when done on the same day a root canal is initiated.

12 A therapeutic apical closure on a permanent tooth, except on a tooth where the root is not fully formed.

13. Retreatment of a root canal within 12 months of the original root canal treatment.

14. A prophylaxis, when done on the same day as root planing. Root planing, when done on the same day as subgingival curettage.

15. An occlusal adjustment, when performed on the same day as the delivery of an occlusal guard.

16. Reline, rebase, or any adjustment or repair within six months of the delivery of a partial denture.

17. Tissue conditioning, when performed on the same day as the delivery of a denture or the reline or rebase of a denture.

18. The completion of claim forms.

19. Temporary crowns.

20. Local Anesthesia, except as provided under Class III Benefits, item (h) on pages 39-40.

Extension of Dental Benefits

Dental and orthodontic benefits may be payable for unfinished dental work performed within 60 days after termination of coverage as if the expenses were incurred while covered if coverage terminates:

• For any reason other than termination of the Fund, and
• Before the completion of a course of dental or orthodontic treatment which began before such termination.

In those cases, Delta Dental evaluates those services in progress to determine what portion may be paid by Delta Dental. Any balance of the total fee not paid by Delta Dental is your responsibility.