DeltaCare Basic and Delta Dental Level II Enhanced Plans Benefits Comparison - Office of Human Resources

PMI DeltaCare Basic and Delta Dental Level II Enhanced Plans Benefits Comparison

For eligible employees in the following categories:

Units 1, 2, 3, 4, 5, 6, 7, 9 and C99, M98, M80 and FERP Annuitants.

Procedure:	PMI DeltaCare Enhanced Plan Charges:	Delta Dental Plan of California Enhanced Level II Plan Pays:
PREVENTATIVE & DIAGNOSTIC DENTISTRY	(No Deductible)*	(No Deductible)*
PROPHYLAXIS (Cleaning)	No charge-limit 2 per 12 month	100% of UCR-limit 2 per 12 months
FlUORIDE APPLICATION	No charge-only to age 19	100% of UCR
ORAL EXAMS	No Charge	100% of UCR—limit 2 per 12 months
SPACE MAINTAINERS	No Charge	100% of UCR (without deductible)
EMERGENCY OFFICE VISITS	No Charge	100% of UCR
X-RAYS	No charge (Full mouth X-rays: 1 set per 24 consecutive months. Bitewings: 1 set (4 films) per every 6-month period.)	100% of UCR (Full mouth x-rays: 1 set in a 3-year period. Bitewings: 1 set per 12 months for age 18 and over.

BASIC DENTISTRY	(No Deductible)*	(Deductible)
FILLINGS	No charge for Amalgam	80% of UCR
ANESTHESIA	Local-no charge General-covered for extractions only and only when medically necessary.	80% of UCR-limited to required anesthesia applied by dentist during oral surgery.
INJECTION OF ANTIBIOTICS	Not covered	80% of UCR
EXTRACTIONS	No Charge	80% of UCR
ORAL SURGERY	No charge	80% of UCR
ENDODONTICS	No Charge	80% of UCR
PERIODONTICS	No Charge	80% of UCR
DENTURE RELINING	No Charge	80% of UCR

PROTHESTIC DENTISTRY	(No Deductible)*	(Deductible)*
CROWNS	No charge, except lab cost of precious metals	80% of UCR
PROSTHETIC APPLIANCE REPAIR	No Charge	80% of UCR
DENTURES	No Charge	80% of UCR
BRIDGES	No charge, except lab cost of precious metals	80% of UCR

Maximum benefit for Preventative, Basic & Prosthetic Dentistry

No maximum*

$2,000 per calendar year per person

ORTHODONTICS

(No Deductible)*
$1,400 maximum co-payment (for covered children up to age 23). $1,600 maximum co-payments for adults. Plus $350 start-up costs for 24-month treatment plan.

(No Deductible)*
50% of UCR. $1000 maximum per patient per case (for employees, spouse & dependant children).

SPECIAL PROVISIONS, LIMITATIONS, EXCLUSIONS
WORK IN PROGRESS WHEN YOU JOIN	Not covered. (Examples: in-progress orthodontics, root canals started, teeth prepped for crowns, etc.)	Only covers charges for services the member receives on and after effective date of coverage.
PREDETERMINATION OF BENEFITS	Not required.	Not required; however, suggested for services proposed over $100.
ALTERNATIVE TO TREATMENT PROVISION	May be additional cost	If dentist determines that alternative treatment is necessary, approval is subject to Delta review.
REFERRAL TO A SPECIALIST	Approval is subject to review by a dental consultant.	N/A
MISSING TEETH	No exclusion against replacing missing teeth.	No exclusion against replacing missing teeth.
OUT-OF-AREA EMERGENCY	Maximum of $100	Out of California-submit dentist's billing statement to Delta Dental of California.
DEDUCTABLE	No deductible	$50 per person up to a maximum of $150 family deductible per calendar year for both basic and prosthetic dentistry. Any part of deductible satisfied during the last 3 months of calendar year is credited toward the next calendar year deductible.
PROSTHETIC REPLACEMENTS	Limited to one each 5 years.	Limited to one each 5 years.

* Refer to the Evidence of Coverage (EOC) booklet. **children under 18 are eligible for 2 sets of bitewing x-rays in a 12-month period. There is a $500 maximum, per year, per child for periodontal procedures only when performed by a specialist (applies to PMI DeltaCare only).

Under certain guidelines Delta Dental participants who are pregnant are eligible to receive an additional cleaning and/or periodontal examination in a calendar year.

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Healthcare Plans

PMI DeltaCare Basic and Delta Dental Level II Enhanced Plans Benefits Comparison

For eligible employees in the following categories: