DELTACARE USA: PROVIDED BY DELTA DENTAL INSURANCE COMPANY YOUR SMILE IS COVERED DENTAL BENEFITS MADE EASY! When you enroll in a DeltaCare USA 1 plan, you ll choose a primary care dentist from our network of carefully screened, private practice dentists. You must visit your primary care dentist to receive benefits. 2 > No restrictions on pre-existing conditions (except work in progress) > Access to specialty care and out-of-area emergency care A PARTNER IN ORAL HEALTH Your DeltaCare USA plan encourages regular dental care with an extensive list of covered services to help you stay healthy. > Low or no copayments for services like cleanings and exams BUDGET-FRIENDLY COSTS With your DeltaCare USA plan, there are no surprises. You ll know your copayments, and your out-of-pocket costs are clearly defined before treatment begins. > No deductibles or maximums for covered services > Pay only your copayment (if any) at the time of treatment CONVENIENT SERVICES We make it easy for you there are no claim forms to complete, and no plan ID card is required to receive treatment. > Access plan information online > Change your primary care dentist by phone or online LEGAL NOTICES: Access federal and state legal notices related to your plan: deltadentalins.com/about/legal/indexenrollee.html 1 The DeltaCare USA plan is underwritten in these states by these entities: AL Alpha Dental of Alabama, Inc.; AZ Alpha Dental of Arizona, Inc.; CA Delta Dental of California; AR, CO, IA, MA, MI, NE, OR, RI, SC, WA, WI Dentegra Insurance Company; DC, DE, FL, GA, KS, TN, WV Delta Dental Insurance Company; HI, ID, IL, IN, KY, MD, MO, NJ, OH, TX Alpha Dental Programs, Inc.; NV Alpha Dental of Nevada, Inc.; UT Alpha Dental of Utah, Inc.; NM Alpha Dental of New Mexico, Inc.; NY Delta Dental of New York, Inc.; PA Delta Dental of Pennsylvania; VA Delta Dental of Virginia. Delta Dental Insurance Company acts as the DeltaCare USA administrator in all these states. These companies are financially responsible for their own products. 2 Verify that the dentist is your selected DeltaCare USA primary care dentist before each appointment. Administered by Delta Dental Insurance Company SCFLSTD HL_DCU_FL15B #89627
USEFUL INFORMATION AT YOUR FINGERTIPS CHECK OUT OUR SMILEWAY WELLNESS PROGRAM Find oral health resources, including a risk self-assessment tool, quizzes, articles, videos and a subscription to Grin!, our free dental wellness e-magazine, at mysmileway.com. FIND A NETWORK DENTIST NEAR YOU Use our convenient Find a Dentist tool and select DeltaCare USA as your network. > Find a dentist near your home or office > Change your primary care dentist SIGN UP FOR AN ONLINE ACCOUNT AT DELTADENTALINS.COM Use your mobile device or desktop to sign up for a free, secure Online Services account. > Review your plan benefits > Access your ID card CONTACT US Need help? Let us know. ONLINE: Visit deltadentalins.com/about/contact/contactus_ddic.html and choose the DeltaCare USA Customer Service form. WRITE TO: DeltaCare USA Customer Service P.O. Box 1803 Alpharetta, GA 30023 CALL TOLL-FREE: 800-422-4234 Customer Service agents are available Monday through Friday, 8 a.m. to 9 p.m., Eastern time. Or, use our interactive automated voice response system, available 24/7. Underwritten by: Delta Dental Insurance Company 1130 Sanctuary Parkway Alpharetta, GA 30009 Administered by: Delta Dental Insurance Company 1130 Sanctuary Parkway Alpharetta, GA 30009 NOTE: THIS IS ONLY A BRIEF SUMMARY OF YOUR PLAN. This brochure is not intended to replace your legally required plan booklet. The Group Dental Service Contract determines the exact terms and conditions of your coverage. Please refer to the Description of Benefits and Copayments and Limitations and Exclusions of Benefits in this brochure for a complete list of covered procedures, copayments, plan limitations and exclusions. You may also consult your Evidence/Certificate of Coverage, which will be mailed to you upon enrollment. If you wish to review an Evidence/Certificate of Coverage prior to enrollment, you may request a copy by calling Customer Service at 800-422-4234. IMPORTANT: Can you read this document? If not, we can have somebody help you read it. For free help, please call Delta Dental at 800-422-4234. IMPORTANTE: Puede leer este documento? Si no, podemos ayudarle. Para obtener ayuda gratis, llame a Delta Dental al 800-422-4234. 重要通知 : 您能讀這份文件嗎? 如有問題, 我們可請他人協助您 如需免費協助, 請電 Delta Dental 800-422-4234 Copyright 2015 Delta Dental. All rights reserved.
DeltaCare USA 15B Plan Highlights The DeltaCare USA plan provides great dental benefits and predictable costs. With defined copayments 1, enrollees know their share of the cost for covered services before their dental visit. Copayments for some of the most common services are listed below. To obtain a complete list of covered services, along with any limitations and exclusions that apply, select the contact us link from the website or call us at 800-422-4234. 2 Summary of Covered Services 2 Category Procedure Code and Description 3 Copayment Amount 1 D0999 - Office visit $5 Diagnostic & Preventive Services (D & P) D0120 - Periodic oral exam established patient D0150 - Comprehensive oral evaluation new or established patient D0210 - Complete series of x-rays D0220 - Periapical x-ray of tooth's root D0230 - Periapical x-ray of tooth s root, each additional image D0272 - Bitewing x-rays (2 images) D0274 - Bitewing x-rays (4 images) D0330 - Panoramic x-ray D1110 - Prophylaxis (cleaning) adult $5 D1120 - Prophylaxis (cleaning) child $5 D1208 - Fluoride treatment D1351 - Sealant per tooth $15 D2140 - Amalgam (silver-colored) filling 1 surfaces $8 D2150 - Amalgam (silver-colored) filling 2 surfaces $12 D2160 - Amalgam (silver-colored) filling 3 surfaces $18 D2330 - Resin (tooth-colored) filling, front tooth, 1 surface $22 Basic Services D2331 - Resin (tooth-colored) filling, front tooth, 2 surfaces $26 D2332 - Resin (tooth-colored) filling, front tooth, 3 surfaces $30 D2391 - Resin (tooth-colored) filling, back tooth, 1 surface $65 D2392 - Resin (tooth-colored) filling, back tooth, 2 surfaces $75 D2393 - Resin (tooth-colored) filling, back tooth, 3 surfaces $85
Category Procedure Code and Description 3 Copayment Amount 1 D3310 - Root canal, front tooth $125 Endodontics D3320 - Root canal, bicuspid tooth $215 D3330 - Root canal, molar tooth $365 Periodontics Oral Surgery D4260 - Periodontal surgery, per quadrant $308 D4341 - Periodontal scaling and root planing four or more teeth per quadrant D4910 - Periodontal maintenance $45 D7140 - Extraction (removal) of a fully exposed tooth $14 D7210 - Surgical extraction or erupted (exposed) tooth $55 D7240 - Extraction (removal) of fully impacted tooth, completely bony $60 $120 D2750 - Crown, porcelain and precious metal $395 D2790 - Crown, precious metal $395 Major Services D5110 - Full upper denture $365 Orthodontics 1 2 3 D6240 - Bridge pontic, porcelain and precious metal $395 D6750 - Bridge crown, porcelain and precious metal $395 D8010 - Limited orthodontic treatment of the primary dentition D8020 - Limited orthodontic treatment of the transitional dentition - child or adolescent to age 19 D8030 - Limited orthodontic treatment of the adolescent dentition adolescent to age 19 D8040 - Limited orthodontic treatment of the adult dentition - adults, including covered dependent adult children D8050 - Interceptive orthodontic treatment of the primary dentition D8060 - Interceptive orthodontic treatment of the transitional dentition D8070 - Comprehensive orthodontic treatment of the transitional dentition - child or adolescent to age 19 D8080 - Comprehensive orthodontic treatment of the adolescent dentition adolescent to age 19 D8090 - Comprehensive orthodontic treatment of the adult dentition - adults, including covered dependent adult children D8660 - Pre-orthodontic treatment examination to monitor growth and development D8680 - Orthodontic retention (removal of appliances, construction and placement of removable retainers) A copayment is the amount the enrollee pays for covered services at the time of treatment. $1,350 $1,900 $1,900 $2,100 The summary of benefits featured above represent the most frequently used services covered under your plan; other services are also covered. All services are subject to the limitations and exclusions of the plan. Copayments and procedure descriptions referenced above are intended to clarify the delivery of benefits under the DeltaCare USA plan and are not to be interpreted as CDT-2014 descriptors or nomenclature, which are under copyright by the American Dental Association. The American Dental Association may periodically change CDT codes or definitions. Such updated codes, descriptors and nomenclature may be used to describe these covered procedures in $25 $275
Keep Smiling Delta Dental PPO SM Stay in network to save Visit a dentist in the PPO 1 network to maximize your savings. 2 These dentists have agreed to reduced fees, and you won t get charged more than your expected share of the bill. 3 Find a PPO dentist at deltadentalins.com. 4 If you can t find a PPO dentist, Delta Dental Premier dentists offer the next best opportunity to save. Unlike non Delta Dental dentists, they have agreed to set fees, and you won t get charged more than your expected share of the bill. Set up an online account Get information about your plan anytime, anywhere by signing up for an Online Services account at deltadentalins.com. Available once your coverage kicks in, this free service lets you check benefits and eligibility information, find a network dentist and more. Check in without an ID card You don t need a Delta Dental ID card when you visit the dentist. Just provide your name, birth date and enrollee ID or social security number. If your family members are covered under your plan, they will need to provide your information. Prefer to take a paper or electronic ID card with you? Simply sign in to Online Services, where you can view or print your card with the click of a button. Coordinate dual coverage If you re covered under two plans, ask your dental office to include information about both plans with your claim, and we ll handle the rest. Understand transition of care Did you start on a dental treatment plan before your PPO coverage kicked in? Generally, multistage procedures are only covered under your current plan if treatment began after your plan s effective date of coverage. 5 You can find this date by logging in to Online Services. Newly covered? Visit deltadentalins.com/welcome. Save with a PPO dentist PPO NON-PPO NON DELTA DENTAL 1 In Texas, Delta Dental Insurance Company offers a Dental Provider Organization (DPO) plan. 2 You can still visit any licensed dentist, but your out-of-pocket costs may be higher if you choose a non-ppo dentist. Network dentists are paid contracted fees. 3 You are responsible for any applicable deductibles, coinsurance, amounts over plan maximums and charges for non-covered services. 4 We recommend verifying before each appointment that your dentist is a PPO dentist. 5 Applies only to procedures covered under your plan. If you began treatment prior to your effective date of coverage, you or your prior carrier is responsible for any costs. Group- and state-specific exceptions may apply. Enrollees currently undergoing active orthodontic treatment may be eligible to continue treatment under Delta Dental PPO. Review your Evidence of Coverage, Summary Plan Description or Group Dental Service Contract for specific details about your plan. LEGAL NOTICES: Access federal and state legal notices related to your plan at deltadentalins.com/about/legal/index-enrollee.html. Copyright 2016 Delta Dental. All rights reserved. HL_PPO_PRE #96083F (rev. 5/16)
Plan Benefit Highlights for: TopBuild Corp. Group No: 17887 Eligibility Deductibles Deductibles waived for Diagnostic & Preventive (D & P) and Orthodontics? Maximums D & P counts toward maximum? Waiting Period(s) Primary enrollee, spouse (includes domestic partner) and eligible dependent children to the end of the month dependent turns age 26 $50 per person / $150 per family each calendar year Yes $1,500 per person each calendar year Yes Basic Benefits Major Benefits Prosthodontics Orthodontics Benefits and Covered Services* Diagnostic & Preventive (D & P) Services Exams, cleanings, x-rays and sealants Basic Benefits Fillings Endodontics (root canals) Covered Under Basic Services Periodontics (gum treatment) Covered Under Basic Services Oral Surgery Covered Under Basic Services Major Benefits Crowns, inlays, onlays, cast restorations and TMJ Prosthodontics Bridges, dentures and implants Delta Dental PPO dentists** Delta Dental Premier dentists** Non-Delta Dental dentists** 100 % 100 % 80 % 60 % 60 % 40 % 60 % 60 % 40 % Orthodontic Benefits Dependent children 50 % 50 % 50 % Orthodontic Maximums $1,000 Lifetime $1,000 Lifetime $1,000 Lifetime * Limitations or waiting periods may apply for some benefits; some services may be excluded from your plan. Reimbursement is based on Delta Dental maximum contract allowances and not necessarily each dentist s submitted fees. ** Reimbursement is based on PPO contracted fees for PPO dentists, Delta Dental Premier contracted fees for Premier dentists and Premier contracted fees for non-delta Dental PPO dentists. Delta Dental Insurance Company 1130 Sanctuary Parkway, Suite 600 Alpharetta, GA 30009 Customer Service 800-521-2651 Claims Address P.O. Box 1809 Alpharetta, GA 30023-1809 deltadentalins.com This benefit information is not intended or designed to replace or serve as the plan s Evidence of Coverage or Summary Plan Description. If you have specific questions regarding the benefits, limitations or exclusions for your plan, please consult your company s benefits representative. HLT_PPO_3COL_DDIC (Rev. 10/05/2016)