Network Dental Plan

Effective July 1, 2012, the Incentive Dental Plan will be replaced with the Network Dental Plan, as described here.

 

Network Dental Plan Schedule of Benefits

The Network Dental Plan is administered by Delta Dental (the service representative).

What You Pay

Network Provider

Non-network Provider

Annual Deductible
NOTE: With new benefit year effective July 1, 2012, you must fulfill a new deductible from July to December 2012. Annual deductible does not apply to examinations, X-rays, cleanings, fluoride treatment, or fissure sealants)

$50 per individual; $150 per family of 3 or more, but not more than $50 for any individual; applies to all covered services and supplies, except as noted below

$75 per individual; $225 per family of 3 or more, but not more than $75 for any individual; applies to all covered services and supplies, except orthodontia

 

Coinsurance Percentage

 

 

Ÿ    Class I (diagnostics, preventive care, restorations using filling materials, oral surgery, periodontics, certain endodontics, and pedodontics)

100% of recognized fee (annual deductible does not apply to examinations, X-rays, cleanings, fluoride treatment, or fissure sealants)

80% of recognized fee after deductible is met

Ÿ    Class II (restorations using crowns, inlays, or onlays)

80% of recognized fee

50% of recognized fee

Ÿ    Class III (prosthodontics)

60% of recognized fee

50% of recognized fee

Ÿ    Class IV (orthodontia)

50% of covered charges (deductible does not apply)

Annual Maximum Benefit
(for Classes I, II, and III)*

$2,000 per individual (network and non-network combined)

$2,000 per individual (network and non-network combined)

Lifetime Maximum Benefit
(for Class IV) **

$2,000 per individual (network and non-network combined)

$2,000 per individual (network and non-network combined)

* When multiple treatment dates are required, the charges apply toward the annual maximum benefit for the benefit year in which the procedure is completed. (A prosthesis is considered complete on the date it is seated or delivered.)

** This lifetime maximum benefit for orthodontia applies to all periods during which the person is covered under any Company-sponsored dental plan.

Covered Dental Services and Supplies

The Network Dental Plan covers 4 classes of services and supplies in accordance with the benefit payment levels and maximums shown in the žNetwork Dental Plan Schedule of Benefits.Ó

Class I Covered Services and Supplies (Covered at 100%)

The plan covers the following Class I services and supplies:

Ÿ    Routine diagnostic examinations, including

* Routine examination, twice in each 1-year period.

* Specialist examinations, up to 3 in a 6-month period.

* Complete mouth or panographic X-rays, once in each 5-year period.

* Supplementary bitewing X-rays, once in each 1-year period.

* Emergency examinations.

* Comprehensive oral examination, once in a 36-month period, which counts as the routine examination once in a 6-month period.

Ÿ    Preventive care, including

* Fissure sealants, through age 14, for permanent molar teeth with intact occlusal surfaces, no decay, and no prior restorations. The repair or replacement of a sealant on any tooth within 36 months is considered part of the original services.

* Prophylaxis (cleaning), either regular or periodontal, twice in each 1-year period, with 2 additional cleanings allowed in the event periodontal disease is present.

* Topical application of fluoride twice in each 1-year period, for dependent children through age›18.

Ÿ    General anesthesia when administered by a licensed dentist in connection with certain covered

* Oral surgery.

* Endodontic surgery.

* Periodontic surgery.

Ÿ    Restorative services (minor restoration), including the restoration of a visibly decayed hard tooth surface (carious lesion) to a state of proper function by using a filling material such as amalgam, silicate, plastic or glass ionomer, or a stainless steel crown. Restorations on the same surface(s) of the same tooth will be covered once in each 24-month period. Composite, plastic, or glass ionomer restorations on a posterior tooth are covered up to the amount allowed for an amalgam restoration.

Ÿ    Oral surgery, including

* Surgical and nonsurgical extractions.

* Preparation of the alveolar ridge and soft tissues of the mouth to insert dentures.

* Ridge extension to insert dentures (vestibuloplasty).

* Treatment of pathological conditions and traumatic facial injuries.

Ÿ    Endodontics, including the following procedures:

* Pulpal and root canal therapy.

* Pulp exposure treatment, pulpotomy, and apicoectomy.

* Root canal treatment on the same tooth, once in each 2-year period.

* Retreatment of the same tooth when performed by a different dental office.

Ÿ    Pedodontics, including space maintainers that are used to maintain space for the eruption of permanent teeth.

Ÿ    Periodontics (surgical and nonsurgical procedures to treat tissues that support the teeth), including

* Gingivectomy.

* Limited adjustments to occlusion (8 or fewer teeth) such as smoothing teeth or reducing cusps.

* Root planing or subgingival curettage, but not both, once in each 24-month period.

Class II Covered Services and Supplies (Covered at 80%)

The plan covers these Class II services and supplies, which are restorative services (major restoration):

Ÿ    Restoration of a visibly decayed hard tooth surface (carious lesion) to a state of proper function by using crowns, inlays, or onlays (gold, porcelain, plastic, or gold-substitute castings or a combination) once in each 5-year period for the same tooth when the tooth cannot be restored effectively with a filling material (amalgam, silicate, or plastic). If a tooth can be restored with a filling material such as amalgam, silicate, or plastic but you choose a more expensive procedure, this plan will cover the cost up to the amount for a filling to repair the condition.

Ÿ    Recementing a crown, inlay, or onlay, once in a 12-month period.

Ÿ    Use of a crown as an abutment to a partial denture, but only when the tooth is decayed to the extent a crown would be required whether or not a partial denture is required.

Ÿ    Temporary crown for a fractured tooth.

Class III Covered Services and Supplies (Covered at 60%)

Under the Network Dental Plan, prosthodontics are in Class III. The plan covers these Class III services and supplies:

Ÿ    A full denture, immediate denture, or overdenture. For any other procedure (such as personalized restorations or specialized treatment), the plan covers up to the appropriate amount for a full denture, immediate denture, or overdenture. Root canal therapy in conjunction with overdentures is limited to 2 teeth per arch.

Ÿ    A cast chrome or acrylic partial denture. If a more elaborate or precision device is used, the plan will cover up to the appropriate amount for covered partial dentures.

Ÿ    Denture adjustments and relines that are provided more than 6 months after initial placement. Later relines and jump rebases (but not both) are covered once in each 12-month period.

Ÿ    Implant and related appliances attached to the implant once in each 5-year period. If you elect an implant and related attached appliances, the plan allows up the amount the plan would have paid for a full or partial denture, once in a 5-year period.

Ÿ    Replacement of an existing prosthetic device, once in each 5-year period, if the device is unserviceable and cannot be made serviceable. (Services to correct the device, if serviceable, are covered.)

Class IV Covered Services and Supplies

Under the plan, orthodontic services and supplies are in Class IV. The plan covers straightening of teeth, including correction or prevention of malocclusion.

Pretreatment Estimate

If your dental care will be extensive, you may ask your dentist to submit a request for a pretreatment estimate, called a žpredetermination of benefits.Ó This predetermination will allow you to know in advance what procedures are covered, the amount the service representative will pay toward the treatment, and your financial responsibility.