GROUP NUMBER:
5720-subs
SCHEDULE OF BENEFITS:
$1,500.00 Maximum benefits for A, B, & C services for each covered person per calendar year and for periodontal splinting under D services.
DEDUCTIBLE:
$50.00 for benefits received per person in B, C, & D with a maximum of $100.00 per family, per calendar year. No deductible on A services.
DEPENDENTS:
Covered to age 19, or 25 if a full-time student. If you pay your premiums on an after-tax basis, children may be added to the dental policy at any time through age 3 years and 1 month. If you pay your premium on a pre-tax basis, contact Human Resources for restrictions that would apply.
CHOOSING YOUR DENTIST:
You can find a list of Delta Dental authorized providers on Delta Dental's web site at http://www.deltadentalar.com/ (Select the Delta Premier option). You may also contact Human Resources to verify your dental provider participation.
Under your Delta program, you may choose any licensed dentist. However, it may be to your advantage to choose a Delta dentist. Here's why: 1) Delta dentists will complete and submit claim forms for you at no charge. If you visit a non-Delta dentist, you may be required to complete the forms yourself or to pay a service charge. 2) If you go to a Delta dentist, payment will be based on a fee agreed upon in advance by Delta and the dentist. This fee is the lowest fee usually charged in your dental office. This means you only have to pay the amount covered by the maximum allowable payment (M.A.P.). 3) Because Delta reimburses Delta dentists directly, they agree to charge you no more than the amount covered by the M.A.P., so you don't have to pay the whole bill and then wait for reimbursement. If you visit a non-Delta dentist, you are responsible for the dentist's entire bill and Delta will reimburse you directly up to the maximum allowable for your program. 4) Non-Delta dentists have not negotiated fees approved by Delta. This means your out-of-pocket expense may be greater if you choose a non-Delta dentist. You also may have to pay the non-Delta dentist in advance for the entire bill. See enclosed list of participating Delta Dental dentists.
This overview contains a general description of your dental care program for your use as a convenient reference. Complete details of your program appear in the group contract between your plan sponsor and Delta Dental Plan of Arkansas, Inc. (DDPAR), which governs the benefits and operation of your program. The group contract would control if there should be any inconsistency or difference between its provisions and the information in this overview.
COVERAGE A @ 100%
- Routine periodic exams, not more than twice in any calendar year.
- Bitewing and periapical x-rays as required.
- Full mouth x-rays once in any three-year period.
- Routine dental prophylaxis not more than twice in any calendar year, including cleaning, scaling, and polishing. Treatment for diseases of the gums not included.
- Topical Fluoride applications for participants under the age of 19, (one treatment per calendar year).
COVERAGE B @ 80%
- Palliative emergency treatment as needed by the participant.
- Fillings including amalgam and composite restorations. (see limitations)
- Periodontics: non-surgical and surgical procedures necessary for the treatment of disease of gum and bone supporting the teeth.
- Endodontics, including pulpal therapy and root canal filling.
- Extractions, simple and surgical.
- Oral Surgery, including pre- and post-operative care.
- Antibiotic injections when given by the dentist.
- Space maintainers to replace prematurely lost teeth of an eligible dependent child to age 16.
- Initial topical application of sealants on permanent caries free (occlusal surface) first and second molars for dependent to age 19 once in a five year period.
- Stainless steel crowns used as restoration to natural teeth for dependent children to age 16, when the teeth cannot be restored with a filling material.
- Repairs and recementing of crowns, inlays, bridgework or dentures.
COVERAGE C @ 50%
- Prosthetics: provides bridges, partial and complete dentures.
- Crowns, inlays, onlays, and veneers when the teeth cannot be restored with a filling material under coverage B.
- Crowns and jackets when the teeth cannot be restored with a filling material.
- Addition of teeth to an existing fixed bridge, partial or full denture.
- Relining or rebasing of dentures, but not more than one of either in a 36-month period.
COVERAGE D @ 50%
- Periodontal splinting for the stabilization of mobile teeth.
LIMITATIONS
- A participating or non-participating dentist need not provide dental services which, for any reason in his/her professional judgment, should not be provided.
- In the event a participant transfers from the care of one dentist to that of another dentist during the course of treatment, or if more than one dentist renders services for one dental procedure, DDPAR shall be liable for not more than the amount for which it would have been liable had but one dentist rendered the services.
- In all cases for which there are optional techniques of treatment carrying different fees, DDPAR shall be liable hereunder only for the treatment carrying the lesser fee.
- No benefits will be payable for services received after the date of termination of this Certificate.
- A prosthetic appliance for the purpose of replacing an existing appliance will not be provided during the first 12 continuous months commencing on the participant's effective date of coverage for Coverage C Services. If such date is different from the original service date, not more often than once in any five-year period and then only in the event that the existing appliance is not, and cannot be, made satisfactory.
- Crowns, inlays, onlays, veneers provided will not be provided more often than once in any five-year period (except for accidental injury from an outside source) and then only in the event that the existing crown or jacket is not, and cannot be, made satisfactory. Said five-year period will be measured from the date on which the existing appliance was last supplied, whether under this contract or under any other prior dental agreement between, or involving as signatories, any of the parties to this membership agreement. The term "existing", used in this paragraph, includes bridges, partial dentures and complete dentures that were placed at the inception of the aforesaid five-year period but which, for whatever reason, is no longer in the possession of the patient.
- Amalgam and composite fillings will be provided no more often than once in a twelve-month period, per surface.
- Composite and acrylic restorations on posterior teeth will not be provided; however, an allowance will be provided for an amalgam restoration.
- Services not submitted within twelve (12) months (365 days) of the date the services were rendered.
- Charges for general anesthesia/IV sedation are not covered except administered in conjunction with covered oral surgery (excluding single tooth extractions & root removal, codes 7110, 7120, and 7130).
EXCLUSIONS
- Services rendered by a dental or medical department maintained by or on behalf of an employer, a mutual benefit association, labor union, trustee or similar person or group.
- Services for which the participant incurs no charge.
- Dental care for any condition, disease or injury for which care, treatment or compensation is available to the participant in whole or in part under a Workers' Compensation or other employer liability law, whether or not a participant claims or receives benefits thereunder, and whether or not any recovery is had by the participant against a third party for such condition, disease or injury. If a participant receives any payment (whether or not for dental services) by award, settlement or otherwise for a condition, disease or injury which he contends resulted from his/her employment he/she agrees to reimburse DDPAR in full up to the amount of such payment for all benefits provided by DDPAR with respect to such illness or injury.
- Dental care provided in a veteran's facility or a hospital operated by the United States of America, or care which is available in whole or in part under the laws of the United States or any state or political subdivision thereof. This exclusion applies to the extent that benefits are provided or would have been provided had the participant enrolled, applied, for, or maintained eligibility for such benefits under any such law.
- Services performed for cosmetic purposes or to correct congenital malformations.
- Charges for courses of treatment, including prosthetics, which were undertaken prior to effective date of coverage.
- Charges for hypnosis.
- Charges for any services not specifically stated (including hospital or prescription drug charges).
- Replacement of dentures that are lost or stolen.
- DDPAR will not duplicate the services provided by another Delta Dental Plan.
- Services rendered by a dentist beyond the scope of his/her license.
- Diseases contracted or injuries or conditions sustained as a result of war or any act of war.
- Services or supplies rendered for conditions related to temporomandibular joint dysfunctions unless optional coverage is purchased.
- Charges for denture adjustments during the first six-month post delivery period.
- Charges for complete occlusal adjustments.
- Charges for bases, liners and anesthetics used in conjunction with permanent restorations.
- Charges for tooth preparation, temporary crowns, bases, impressions, local anesthesia or other services, which are part of and included in the fee for the complete procedure. Separate fees may not be charged.
- Charges for any service, supply, surgery or appliance in connection with orthodontic diagnostic procedures, or treatment.
- Charges for replacing or repairing an orthodontic appliance.
- Charges for any services covered under a "terminal liability," extension of benefits or similar provision of a previous dental carrier that was replaced by this program.
- 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, or implantology techniques.
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