Retiree voluntary benefits - Delta Dental PPO Plus Premier™

Plan highlights
Lifetime deductible – $100 (once per lifetime as long as policy is in force – does not apply to preventive and diagnostic)
Waiting period – None, coverage begins as of the coverage effective date if you enroll when initially eligible
Calendar year maximum	Premium plan $2,000	Standard plan $1,500	Basic plan $1,000

Delta Dental PPO Plus Premier™ benefits*

Preventive & diagnostic	Premium plan	Standard plan	Basic plan
Dental evaluations	100%	100%	100%
Routine cleanings	100%	100%	100%
Bitewing X-rays	100%	100%	100%
Full-mouth X-rays (a series of individual X-rays or a panoramic X-ray)	100%	100%	100%
Fluoride	100%	100%	100%
Sealants on the decay-free, biting surface of permanent molars	100%	100%	100%
Space maintainers when a primary molar tooth is prematurely lost	100%	100%	100%
Emergency treatment to relieve pain	100%	100%	100%
Basic services	Premium plan	Standard plan	Basic plan
Composite (tooth colored) fillings or Amalgam (silver) fillings on any teeth	80%	80%	50%
Non-surgical extractions	50%	50%	50%
Major services	Premium plan	Standard plan	Basic plan
Crowns – Repair of teeth with crowns when they cannot be restored with other filling materials	50%	50%	50%
Endodontics – The care of teeth with damaged nerves, such as root canal treatment	50%	50%	50%
Periodontics – The treatment of diseases of the gums and supporting bone, such as scaling and root planing	50%	50%	50%
Oral surgery – Surgical extractions and other dental surgery	50%	50%	50%
Fixed and removable prosthodontics – Dental services and appliances to replace missing teeth, such as dentures and bridges (excluding implants), including repairs	50%	50%	50%
Implants – Dental services for surgical placement of implant body and implant abutment supported crowns	50%	50%	50%
Adjunctive general services – Dental services include general anesthesia, and palliative care (temporary treatment of dental pain)	50%	50%	50%
Additional services	Premium plan	Standard plan	Basic plan
Oral Health Enhancement - 2 additional cleanings per year for members with a history of periodontal disease
Integrative Care - 2 additional cleanings per year for members with certain chronic health conditions

Enrollment and eligibility rules apply

Enrollment
Retired employees may enroll in this plan during the initial open enrollment period offered to eligible retirees as defined by your former employer.

Thereafter, employees who retire may enroll and select any of the three retiree plans upon the date of retirement or within (90) days of retirement. Benefits will be effective the first of the month following the date of enrollment.

If you are a retiree enrolled in COBRA or another qualifying dental plan prior to enrolling in the retiree plan

You will have the option to enroll within 90 days in any of the three retiree dental plans upon termination of COBRA or qualifying dental plan. Benefits will be effective the first of the month following the date of enrollment upon validation of prior coverage.

If you do enroll as a late entrant:

If you don’t enroll upon initial eligibility as a retiree or within the 90-day period following the date of your retirement, upon termination of COBRA or another qualifying dental plan, you may enroll as a late entrant. A 12-month waiting period will apply to major services for the Premium and Standard plans. No waiting period will apply to the Basic plan. Your benefits will be effective on the first of the month on following the date of enrollment.