Dental Plan Benefits Summary

Delta Dental PPO™ (Point-of-Service) Summary of Dental Plan Benefits For Group# 1157-0001, 0002, 0099 The Jay School Corporation 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, 100% 100% 100% cleanings, fluoride, and space maintainers Emergency Palliative Treatment – to temporarily 100% 100% 100% relieve pain Sealants – to prevent decay of permanent teeth 100% 100% 100% Brush Biopsy – to detect oral cancer 100% 100% 100% Radiographs – X-rays 100% 100% 100% Basic Services Minor Restorative Services – fillings and crown repair 80% 80% 80% Occlusal Guards/Adjustments – bite guards and 80% 80% 80% occlusal adjustments Oral Surgery Services – extractions and dental surgery 80% 80% 80% Other Basic Services – misc. services 80% 80% 80% Relines and Repairs – to prosthetic appliances 80% 80% 80% Major Services Endodontic Services – root canals 50% 50% 50% Periodontic Services – to treat gum disease 50% 50% 50% Major Restorative Services – crowns 50% 50% 50% Prosthodontic Services – bridges, implants, dentures, 50% 50% 50% and crowns over implants Orthodontic Services Orthodontic Services – braces 50% 50% 50% Orthodontic Age Limit – through age 18 through age 18 through age 18 and under and under and under * 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 and you are responsible for that difference.  Oral exams (including evaluations by a specialist) are payable twice per calendar year.  Prophylaxes (cleanings) are payable twice per calendar year.  People with specific at-risk health conditions may be eligible for additional prophylaxes (cleanings) or fluoride treatment. The patient should talk with his or her Dentist about treatment.  Fluoride treatments are payable twice per calendar year for people age 18 and under.  Bitewing X-rays are payable twice per calendar year and full mouth X-rays (which include bitewing X-rays) or a panorex are payable once in any three-year period.  Sealants are payable once per tooth per three-year period for first permanent molars for people age eight and under and second permanent molars for people age 13 and under. The surface must be free from decay and restorations.  Composite resin (white) restorations are payable on posterior teeth. INPPOSUM1122 KR#05809057