Retiree Dental Summary

INPPOSUM123 KR#84407221 Delta Dental PPO™ (Standard) Summary of Dental Plan Benefits For Group #0414-0001 DePauw University Retirees 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 PPO™ Dentist Delta Dental Premier® Dentist Nonparticipating Dentist Plan Pays Plan Pays* Plan Pays* Diagnostic & Preventive Diagnostic and Preventive Services – exams, cleanings, fluoride, and space maintainers 100% 100% 100% Palliative Treatment – to temporarily relieve pain 100% 100% 100% 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 50% 50% 50% Endodontic Services – root canals 50% 50% 50% Periodontic Services – to treat gum disease 50% 50% 50% Oral Surgery Services – extractions and dental surgery 50% 50% 50% Major Restorative Services – crowns 50% 50% 50% Other Basic Services – misc. services 50% 50% 50% Relines and Repairs – to prosthetic appliances 50% 50% 50% Major Services Prosthodontic Services – bridges, implants, dentures, and crowns over implants 50% 50% 50% * When you receive services from a Delta Dental Premier or Nonparticipating Dentist, the percentages in this column indicate the portion of Delta Dental's PPO Dentist Schedule 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.  Three oral exams (including evaluations by a specialist) are payable 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 once per calendar year for people age 18 and under.  Bitewing X-rays are payable once 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 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 all teeth, including posterior teeth.  Implants are payable once per tooth in any five-year period. Implant related services are Covered Services.  Crowns over implants are payable once per tooth in any five-year period. Services related to crowns over implants are Covered Services.