2012-038 Human Resources - Delta Dental Claims & Administrative fees

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- Have executed a written agreement or civil contract which defines their domestic partner relationship and their liabilities with respect to their assets and debts. - Not Medicare eligible. E. F. G. Where two legally married Subscribers are both eligible for coverage under this Contract, they may be enrolled together on one application card or separately on individual application cards, but not both. Dependent children may only be enrolled on one application card. Delta Dental will not coordinate benefits for married Subscribers who are both eligible under this Contract. Waiting Period: All new Subscribers (and their dependents, if covered above), defined as eligible Subscribers added to the covered group who are hired after the effective starting date of the Contract will be eligible for enrollment on the first day of the month following date of hire. Deductible: $50 deductible per person total per calendar year limited to a maximum deductible of $150 per family per calendar year. The deductible does not apply to diagnostic and preventive services, emergency palliative treatment, x-rays, sealants, brush biop"sy, periodontal maintenance, and orthodontic services. Covered Services: Premier Non- Dentist Participating Dentist Plan Pavs Plan Pavs Diagnostic and Preventive Services - includes exams, cleanin s, fluoride, and s ace maintainers 100% . ;, .~ ,;. ~ 100% ~ 100% Emergency Palliative Treatment - to temporarily relieve ain 1D0°~o ~ ; ~ = :_....: ~ < ~...:9 ..~ 100% l OQ% Sealants - to revent deca of permanent teeth -, ' 10U°la ;~ ~ ' 100%0 100% Brush Biopsy - to detect oral cancer ~ LOQ"/o ;: ~ ~~s~ 100% 100% Radio ra hs - X-rays ~_:100°~0 ~';, .. ~: ~~~ ~~ ~~~~ 100% ~ 100% Periodontal Maintenance - cleanings by a s ecialist ~ QO°la ~ ~ ~°, 100%0 100% Minor Restorative Services - fillings and crown g~o~« ? ~ 85% 85% re air „ ~ ~ Endodontic Services - root canals $5% '; 85%~ ~~~~ gs~/a Periodontic Services - to treat gum disease `` 85% ~.~:' : ~~ 85%0 ' ~~ 85% Oral Surgery Services - extractions and dental ;: g$o~o 85% 85% sur ery Other Basic Services - misc. services 85% .:: , 85%0 85% Ma'or Restorative Services - crowns '~~ : 50~~ ,i ~ 50% `~~ 50°/a Relines and Re airs - to bridges and dentures ; 50% 50% 50% Prosthodontic Services - includes brid es, LL implants, and dentures g ~~ 50°~ 50% 50% ~ ~ Orthodontic Services - includes braces ~ ;: 50°l0 ,:: = ~~ ~ 50% 50% ~ Orthodontic Age Limit - No Aqe Lirriit ,- No A¢e Limit No Aee Limit - Oral exams (including evaluations by a specialist) are payable twice per calendar year. - Prophylaxes (cleanings) are payable twice per calendar year. - Fluoride treatments are payable twice per calendar year for people up to age 19. - Sealants are payable once per tooth per lifetime for the occlusal surface of first and second permanent molars up to age 16. The surface must be free from decay and restorations. , - Reline and rebase of dentures are payable once in any two-year period. - Implants and implant related services are payable once per tooth in any five-year period. - Vestibuloplasty is a Covered Service. - Bitewing X-rays are payable twice per calendar year. Full mouth X-rays (which include bitewing X- rays) are payable once in any three-year period.