DELTA DENTAL INDIVIDUAL AND FAMILY – VALUE PLUS PLAN BENEFITS SUMMARY EFFECTIVE DATE OF COVERAGE: 01/01/2015 POLICY YEAR: JANUARY 1 THROUGH DECEMBER 31 This is a summary of benefits. The information shown here is not a guarantee of payment. Refer to the Certificate of Coverage for the full plan terms. The Certificate includes any limitations or exclusions not seen here. To be covered, services must be dentally necessary and appropriate as per our review guidelines. UNDER AGE 19 MAXIMUMS Annual Maximum None Medically Necessary Orthodontic Lifetime Maximum None Maximum Lifetime Cap Unlimited In Network Out-‐of-‐Pocket Maximum (per member) $350 for one individual under age 19 / $700 for two or more individuals under age 19 Out-‐of-‐Network Out-‐of-‐Pocket Maximum (per member) None AGE 19 & OVER MAXIMUMS Annual Maximum Maximum Lifetime Cap $1,750 Unlimited Indicates Pre-‐treatment Estimate recommended. Indicates Pre-‐treatment Estimate recommended. Indicates Prior Authorization required. Procedure Out of Network* 100% 100% 100% 100% 0% 0% 0% 0% Twice per calendar year One set per calendar year Once every 60 months As required 100% 100% 100% 0% 0% 0% Space maintainers 100% 0% Twice per calendar year Twice per calendar year Once every 24 months on unrestored permanent molars Once every 60 months for lost deciduous (baby) teeth Minor Restorative Amalgam (silver) fillings Composite (white) fillings 50% 50% 0% 0% For front teeth only. For composite fillings on back teeth, the plan pays up to what would have been paid for an amalgam (silver) filling. Patient is responsible for the balance up to the dentist’s charge. Repairs to existing partial or complete dentures Recementing crowns or bridges Rebasing or relining of partial or complete dentures Major Restorative 50% 0% 50% 50% Crowns (over natural teeth when teeth cannot be restored with regular fillings), build ups, posts and cores 50% Diagnostic Oral Exam Bitewing x-‐rays Complete x-‐ray series or panoramic film Single x-‐rays Preventive Cleaning Fluoride treatment Sealants Form #DDRI201-IND&FAMX_Value Plus Plan Frequency / Limitations + In Network Procedure Diagnostic Oral Exam Bitewing x-‐rays Complete x-‐ray series or panoramic film Single x-‐rays Preventive Cleaning Minor Restorative Amalgam (silver) fillings Composite (white) fillings Once per calendar year 0% 0% Once every 60 months Once every 60 months 0% Replacement limited to once every 60 months Out of Network* 100% 100% 100% 100% 0% 0% 0% 0% Twice per calendar year One set per calendar year Once every 60 months As required 100% 0% Twice per calendar year 80% 80% 0% 0% For front teeth only. For composite fillings on back teeth, the plan pays up to what would have been paid for an amalgam (silver) filling. Patient is responsible for the balance up to the dentist’s charge. Repairs to existing partial or complete 80% dentures Recementing crowns or bridges 80% Rebasing or relining of partial or 80% complete dentures Major Restorative (12 month waiting period) Crowns (over natural teeth when 50% teeth cannot be restored with regular 0% Once per calendar year 0% 0% Once every 60 months Once every 60 months 0% Replacement limited to once every 60 months Frequency / Limitations + In Network fillings), build ups, posts and cores Delta Dental of Rhode Island | 10 Charles Street | Providence, RI 02904 | www.deltadentalri.com 6/2014 DELTA DENTAL INDIVIDUAL AND FAMILY – VALUE PLUS PLAN BENEFITS SUMMARY (Continued) UNDER AGE 19 AGE 19 & OVER Procedure Endodontics Root canal therapy Periodontics Periodontal maintenance following active therapy Root planing and scaling Periodontics (Continued) Osseous (bone) surgery In Network Out of Network* Frequency / Limitations 50% 0% 50% 0% 50% 0% + 0% Out of Network* 80% 0% 80% 0% Twice per calendar year 80% 0% Once per quadrant every 24 months Osseous (bone) surgery 50% 0% Once per quadrant every 36 months (bone grafts are not covered) Twice per calendar year Endodontics Root canal therapy Periodontics Periodontal maintenance following active therapy Once per quadrant every 24 months Root planing and scaling Periodontics (12 month waiting period) Once per quadrant every 36 months (bone grafts are not covered) Frequency / Limitations + In Network 50% Procedure Gingivectomies 50% 0% Once per site every 36 months Gingivectomies 50% 0% Once per site every 36 months Soft tissue grafts 50% 0% Once per site every 60 months Soft tissue grafts 50% 0% Once per site every 60 months Crown lengthening Prosthodontics 50% 0% Once per site every 60 months 50% 0% Once per site every 60 months Bridges and crowns over implants 50% 0% Bridges and crowns over implants 50% 0% Partial and complete dentures 50% 0% Partial and complete dentures 50% 0% Surgical placement of endosteal implant and abutment Extractions and Oral Surgery Extractions and other routine oral surgery when not covered by a patient’s medical plan Orthodontics 50% 0% Replacement limited to once every 60 months Replacement limited to once every 60 months Once per tooth site per lifetime 50% 0% Replacement limited to once every 60 months Replacement limited to once every 60 months Once per tooth site per lifetime 50% 0% 80% 0% Medically necessary braces and related services. Requires prior authorization. No payment will be made if not obtained. 50% 0% Covered only when medically necessary and performed by an orthodontist. Patient must have severe and handicapping malocclusion as defined by HLD index score of 28 or higher and/or one or more auto qualifiers. One procedure per lifetime. 50% 0% Twice per calendar year Other Services Palliative treatment (minor procedures necessary to relieve acute pain) 50% 0% Other Services Palliative treatment (minor procedures necessary to relieve acute pain) General anesthesia or intravenous (I.V.) sedation for certain complex surgical procedures Dependent children are covered under these benefits up until the end of the month that they turn age 19. Crown lengthening Prosthodontics (12 month waiting period) Surgical placement of endosteal implant and abutment Extractions and Oral Surgery Extractions and other routine oral surgery when not covered by a patient’s medical plan 80% 0% Twice per calendar year General anesthesia or intravenous (I.V.) sedation for certain complex surgical procedures 80% 0% Occlusal guards 50% 0% Once per lifetime Dependent children covered under a family plan are covered under these benefits from age 19 up until the end of the month that they turn age 26. Children under age 19 have different coverage. * Out-of-network care: This Plan does not pay for services received out-of-network. You pay the non-participating dentist’s charge. To find a participating dentist, go to www.deltadentalri.com. Time limits on services (e.g. 6, 12, 24, 36, or 60 months) are figured to the exact day. Services are then covered the following day. For example, when a service is covered once every 12 months, if the service was done on July 1, it will not be covered again until the following year on July 2 or after. Delta Dental of Rhode Island | 10 Charles Street | Providence, RI 02904 | www.deltadentalri.com +