DENTAL BENEFITS

The dental benefits are designed to help pay a portion of your dental expenses. Delta Dental PPO is a preferred provider organization program offered by Delta Dental, the nation’s largest and most experienced dental benefits carrier.

Eligibility

Plan I
Plan I Earned, Self-Pay and Senior Performer participants and their eligible dependents are eligible for the dental benefits.

Plan II
Plan II Earned and Self-Pay participants who have a minimum of three years of Earned eligibility and their eligible dependents are eligible for the dental benefits. All Earned Health Plan years, including the years you chose not to pay the premium, will count toward the three year requirement.

Lower Cost Self-Pay participants are covered under the dental plan they were covered under when they had Earned Eligibility.

Selecting a Dentist
There are two types of dentists in the Delta network:

• Delta Dental PPO dentists
• DeltaPremier dentists

When you use a Delta Dental PPO dentist, your diagnostic and preventive services are covered at 100% and are not subject to the deductible. Payment is based on a preapproved fee and the dentist will file your claims for you.

When you use a DeltaPremier dentist, payment is based on a pre-approved fee. These dentists will file your claim forms for you, but diagnostic and preventive services are subject to the deductible and paid at less than 100%.

To find a Delta Dental PPO dentist:

• Call Delta Dental at 1-800-427-3237.
• Visit Delta’s Web site:
  www.deltadentalca.org/sagph.
• Call your dentist and ask if he or she is a Delta Dental PPO dentist or DeltaPremier dentist.

Using a Non-Network Dentist
When you use a dentist outside of the available networks, or you reside outside the United States, payment is based on the Plan’s Allowance or the fee the dentist actually charges, if less. If your dentist’s fees exceed the Plan’s Allowance, you are responsible for the difference between the Plan’s payment and the dentist’s actual charges. In addition, you will be responsible for your regular coinsurance and any deductible that may apply. Finally, your non-network dentist may collect payment up front and may not be willing to file a claim form for you.

Deductible
Dental benefits are payable once you satisfy a calendar year deductible. This is a separate deductible from the hospital, major medical and prescription drug deductibles. The amount of the dental deductible differs for Plan I and Plan II as noted below:

• Plan I - $75 per person/$200 per family*
• Plan II - $100 per person/no family maximum

* If two or more members of your family are injured in the same accident, only one deductible will be applied against all the
covered dental charges incurred during any one year as a result of such accident.

Note: There is no deductible for diagnostic and preventive services when you use a Delta Dental PPO network dentist.

If your eligibility changes from Plan I to Plan II during a calendar year, any charges that were applied toward your Plan I deductible will apply toward the Plan II deductible. If your eligibility changes from Plan II to Plan I during a calendar year, the reverse is also true.

Maximum Benefit
The maximum amount the Plan will pay for all covered dental charges in a calendar year is:

• Plan I - $2,500 per person
• Plan II - $1,000 per person

If your eligibility changes from Plan I to Plan II during a calendar year, any charges that were applied toward your Plan I annual maximum will apply toward the Plan II annual maximum. If your eligibility changes from Plan II to Plan I during a calendar year, the reverse is also true.

Pre-Treatment Estimate
The dental program contains this optional feature which allows you to determine in advance how much the Plan will pay on
extensive dental procedures before they are performed. Please refer to the section on filing a claim on page 75.

Covered Dental Charges and Limitations
Covered dental charges are the charges of a dentist or physician for the services and supplies required for dental care and treatment of any disease, defect or accidental injury, or for preventive dental care. Covered dental charges do not include any charge in excess of the charge customarily made for similar services and supplies by dentists or physicians in the locality concerned. Where alternative services or supplies are customarily available for such treatment, covered dental charges will only include the least expensive service or supply resulting in professionally adequate treatment.

Charges must be incurred and the services and supplies furnished while you or your dependent are covered. A charge is incurred as of the date the service is rendered or the supply is furnished, with the following three exceptions:

1. With respect to fixed bridgework, crowns, inlays, onlays, or gold restorations, the charge is incurred on the first date of preparation of the tooth or teeth involved.
2. With respect to full or partial dentures, the charge is incurred on the date the impression is taken.
3. With respect to endodontics, the charge is incurred on the date the tooth is opened for root canal therapy.

Covered charges for both a temporary and permanent prosthesis will be limited to the charge for a permanent one.

Covered charges for a crown or gold filling will be limited to the charge for an amalgam filling unless the tooth cannot be restored with amalgam.

Covered charges for porcelain or plastic veneer crowns (tooth colored crowns) may be limited to the charge for a metal crown on certain teeth in the back of the mouth. You may want to obtain a pre-treatment estimate so you will know how much the Plan will pay.

Charges for amalgam fillings, gold fillings, inlays and crowns are payable when they are necessary to restore the structure of the tooth broken down by decay or non-accidental injury.

Implants (appliances inserted into bone or soft tissue in the jaw, usually to anchor a denture) are not covered by the Plan. However, if implants are provided along with a covered prosthodontic appliance, the Plan will allowthe cost of a standard partial or complete denture toward the cost of implants and the prosthodontic appliance when the appliance is completed. If such an allowance is made, the Plan will not pay for any replacement for five years following the completion of the service.

Questions
If you need help or have any questions, you can call the Plan Office or contact Delta Dental:

On the Internet –
www.deltadentalca.org/sagph

By Telephone – 1-800-846-7418

Non-Covered Dental Expenses

• Accidental injury to natural sound teeth. (This benefit is provided under the major medical portion of the Health Plan. See page 35.)
• Adjustments to prosthesis within six months from installation.
• Anesthesia, other than general anesthesia administered by a licensed dentist in connection with a covered oral surgery and anesthesia used for periodontal procedures.
• Extra-oral grafts (grafting tissues from outside the mouth to oral tissue).
• Hospital costs and any additional fee charged by the dentist for hospital treatment.
• Intravenous sedation.
• Orthodontic services, other than for related extractions or space maintainers.
• Prescribed or applied therapeutic drugs, pre-medication or analgesia.
• Procedures, restorations and appliances to increase vertical dimension or to restore occlusion.
• Replacement of existing restorations for any purposes other than active tooth decay.
• Services with respect to congenital or developmental malformations, or services and supplies cosmetic in nature, including but not limited to cleft palate, upper or lower jaw malformations, enamel hypoplasia (lack of development), fluorosis (discoloration of the teeth) and anodontia (congenitally missing teeth).
• Services and supplies not recognized as generally accepted dental practice.
• 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, including but not limited to equilibration and periodontal splinting.
• Specialized techniques involving precision attachments, personalization or characterization.
• Training in or supplies used for dietary counseling, oral hygiene or plaque control.
• Temporomandibular joint syndrome (TMJ) treatment. (In certain circumstances, this benefit may be provided under the major medical portion of the Health Plan. See page 37.)
• Treatment by someone other than a dentist or physician, except when performed by a duly qualified technician under the direction of a dentist or physician.

Please also refer to “General Exclusions” on page 64.

Loss of Coverage
When you lose your eligibility for dental benefits, coverage will still be provided for services or supplies furnished within 90 days after coverage terminates if the charges were incurred while the individual was covered.

Dental Benefits

If your eligibility changes from Plan I to Plan II during a calendar year, any charges that were applied toward your Plan I deductible or annual maximum will apply toward the Plan II deductible and annual maximum. If your eligibility changes from Plan II to Plan I during a calendar year, the reverse is also true.

Covered Services	Delta Dental PPO Network Dentists	Delta Premier or Non- Network Dentists
Diagnostic and Preventive Services Oral examination – once every six months Cleanings – two per calendar year* X-rays: Bitewing – once every six months Full mouth – once every three years Fluoride treatment – children under age 19, once per calendar year Sealants – children under age 14, once every three years Biopsy/tissue examination Emergency palliative treatment Consultation by a covered specialist Space maintainers Diagnostic casts	Plan I No deductible; 100% of dentist’s fees Plan II No deductible; 100% of dentist’s fees	Plan I 75% of Plan’s Allowance after deductible Plan II 60% of Plan’s Allowance after deductible
Basic Services Restorative – amalgam, silicate or composite fillings Oral surgery – extractions including surgical removal of teeth Endodontics – root canal therapy Periodontics – treatment of gums and bones supporting teeth General anesthetics for oral surgery only Injectable antibiotics Addition of teeth to existing denture Repair and rebasing of existing dentures	Plan I 75% of dentist’s fees after deductible Plan II 60% of dentist’s fees after deductible	Plan I 75% of Plan’s Allowance after deductible Plan II 60% of Plan’s Allowance after deductible
Major Services Restorative – gold fillings, inlays and crowns Crown replacement – if crown is over three years old Gold fillings, inlays, onlays and cast resorations - services on the same tooth limited to once every five years Fixed bridges/partial or full dentures – if required to replace lost natural teeth or an existing prosthesis which is over five years old and cannot be made serviceable	Plan I 50% of dentist’s fees after deductible Plan II 50% of dentist’s fees after deductible	Plan I 50% of Plan’s Allowance after deductible Plan II 50% of Plan’s Allowance after deductible

* Individuals receiving post-periodontal surgery maintenance from a network dentist are entitled to cleanings and scalings up to four times per year.