Delta Dental PPO Plan Benefits Summary for Elkhart Community Schools

Delta Dental PPO™ (Point-of-Service) Summary of Dental Plan Benefits For Group# 1300-0001, 0002, 0099 Elkhart Community Schools This Summary of Dental Plan Benefits should be read along with your Certificate. Your Certificate provides additional information about your Delta Dental plan, including information about plan exclusions and limitations. If a statement in this Summary conflicts with a statement in the Certificate, the statement in this Summary applies to you and you should ignore the conflicting statement in the Certificate. The percentages below are applied to Delta Dental's allowance for each service and it may vary due to the dentist's network participation.* Control Plan – Delta Dental of Indiana Benefit Year – January 1 through December 31 Covered Services – Delta Dental Delta Dental Nonparticipating PPO™ Dentist Premier® Dentist Dentist Plan Pays Plan Pays Plan Pays* Diagnostic & Preventive Diagnostic and Preventive Services – exams, 80% 80% 80% cleanings, fluoride, and space maintainers Emergency Palliative Treatment – to temporarily 80% 80% 80% relieve pain Sealants – to prevent decay of permanent teeth 80% 80% 80% Brush Biopsy – to detect oral cancer 80% 80% 80% Radiographs – X-rays 80% 80% 80% Basic Services Minor Restorative Services – fillings and crown repair 80% 80% 80% Endodontic Services – root canals 80% 80% 80% Periodontic Services – to treat gum disease 80% 80% 80% Oral Surgery Services – extractions and dental surgery 80% 80% 80% Major Restorative Services – crowns 80% 80% 80% Other Basic Services – misc. services 80% 80% 80% Relines and Repairs – to prosthetic appliances 80% 80% 80% TMD Treatment – treatment of the disorder of the 80% 80% 80% temporomandibular joint, including related films Major Services Prosthodontic Services – bridges, implants, dentures, 80% 80% 80% and crowns over implants Orthodontic Services Orthodontic Services – braces 60% 60% 60% Orthodontic Age Limit – Dependent Dependent Dependent Children up to Children up to Children up to age 19 age 19 age 19 * When you receive services from a Nonparticipating Dentist, the percentages in this column indicate the portion of Delta Dental's Nonparticipating Dentist Fee that will be paid for those services. This amount may be less than what the Dentist charges or Delta Dental approves and you are responsible for that difference.  Oral exams (including evaluations by a specialist) are payable twice per calendar year. Screening and assessment of a patient are payable twice per calendar year.  Prophylaxes (cleanings) are payable twice per calendar year. Two additional prophylaxes are payable per calendar year for individuals with a documented history of periodontal disease. Full mouth debridement is payable once in any three-year period.  Fluoride treatments are payable once per calendar year for people age 23 and under.  Space maintainers are payable once per area per lifetime for people age 15 and under.  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.  TMD films are Covered Services. Cone beam imaging are payable once every five years. KR#64690433