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Delta Dental Individual and FamilyTM Agave Plan - 764

This plan is a Delta Dental PPOSM plan that leverages the PPO network. While members can see any licensed dentist, they’ll have the lowest out-of-pocket costs when they see a PPO dentist.

Delta Dental PPO Dentist – These in-network dentists agreed to accept lower reimbursement for services so members save the most money.

Delta Dental Premier Dentist – These in-network dentists also accept discounted reimbursement for services, but their discount is not as steep. Members can be billed for the difference between the Delta Dental PPO dentist fee and the Delta Dental Premier dentist fee.

Out-of-Network Dentist – These dentists have not agreed to discount their rates for service, so members who see an out-of-network dentist will have the highest out-of-pocket costs. Members are responsible for paying the full fee charged by the dentist and can submit for reimbursement at the non-participating table of allowance.

SUMMARY OF BENEFITS

DEDUCTIBLE1,2 YOU PAY

Per person, per benefit year $50

ANNUAL MAXIMUM BENEFIT1 DELTA DENTAL PAYS Per person, per benefit year $1,000

Benefits and Covered Services2 Co-insurance3 Frequencies and Limitations

Type 1: Preventive Services Delta Dental Pays3 How Many How Often

Exams, Evaluations or Consultations 90% 2 Benefit Year

Routine Cleanings 90% 2 Benefit Year

Topical Application of Fluoride (under age 16) 90% 1 Benefit Year

Space Maintainers for missing posterior primary (baby) teeth (under age 14) 90% 1 Lifetime

Sealants – One treatment per tooth for permanent molars & bicuspids (under age 15) 90% 1

3-year Period4

Type 2: Basic Services Delta Dental Pays3 How Many How Often

Bitewing or Vertical Bitewing X-rays 40% 1 Benefit Year

Complete Series (Full Mouth) / Panoramic X-rays 40% 1 5-year Period4

Simple Extractions 40% No Limit No Limit

Amalgam (silver-colored) Fillings per tooth surface 40% 1 2-year Period4

B0518-764 Page 2 of 4

Composite (tooth-colored) Fillings per tooth surface - Front teeth only 40% 1

2-year Period4

Emergency (Palliative) treatment for the relief of pain 40% No Limit No Limit

Prefabricated Stainless Steel Crowns – Primary Teeth 40% 1 2-year Period4 Periodontal Maintenance (following active periodontal treatment) - Interchangeable with Routine Cleanings 40% 2 Benefit Year

Type 3A: Major Services (A 6-month waiting period applies to these services)5 Delta Dental Pays

3 How Many How Often

Non-Surgical treatment of Gum Disease 30% 1 2-year Period4

Surgical treatment of Gum Disease 30% 1 3-year Period4

Root Canal Treatment per tooth (Permanent Teeth) 30% 1 Lifetime

Pulpotomy per tooth (Primary (baby) Teeth) 30% 1 Lifetime

Additional Endodontic procedures, such as retreatment 30% 1 3-year Period4

Surgical Extractions 30% No Limit No Limit

General Anesthesia and Intravenous Sedation/Analgesia for surgical extractions 30% No Limit No Limit

Denture Relines and Rebases 30% 2 Benefit Year

Denture Adjustments 30% 2 1-year Period4 Crown, Bridge and Denture Repair – Repair of such appliances to their original condition 30% No Limit No Limit

Type 3B: Major Services (A 9-month waiting period applies to these services)5 Delta Dental Pays

3 How Many How Often

Special Restorative 30% 1 5-year Period4

Implant per tooth 30% 1 5-year Period4

Cast Crowns - Onlays 30% 1 5-year Period4

Prefabricated Stainless Steel Crowns – Permanent Teeth 30% 1 5-year Period4 Bridges – Does not provide for lost, misplaced or stolen bridges 30% 1

5-year Period4

Complete Dentures – Does not provide for lost, misplaced or stolen dentures 30% 1

5-year Period4

Partial Dentures – Does not provide for lost, misplaced or stolen dentures 30% 1

5-year Period4

1 Deductible and annual maximum benefit amounts represent a combination of all networks and are not cumulative. 2 Deductible applies to all services. Delta Dental recommends asking for a predetermination (pre-treatment estimate) for any services over $250.

3 This dental plan reimburses all procedures based on the Delta Dental PPO fee. Premier and out-of-network dentists may bill you for charges above the allowed Delta Dental PPO fee. As a result, you may incur higher out-of-pocket costs when seeing a Premier or out-of-network dentist.

4 The interval begins with your last date of service. 5 Waiting period may be waived if covered under a prior PPO/Indemnity plan with no more than a 63-day gap in coverage.

For additional plan information, please visit our website at www.DeltaDentalCoversMe.com or call us at 888.899.3734.

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INDIVIDUAL PLAN EXCLUSIONS, LIMITATIONS & ADDITIONAL INFORMATION

General Limitations - All Services

A. If an eligible person with a covered condition selects a service that is not provided for under the terms of this Dental Coverage Policy, or selects specialized techniques rather than standard dental services, Delta Dental will pay the applicable percentage of the allowable fee for the standard covered dental service and the patient is responsible for the difference between what Delta Dental paid and the dentist’s fee.

B. Pre- and post-operative procedures are considered part of any associated covered service.

Benefit will be limited to the covered amount for the covered services.

C. Local anesthesia is considered a component of any procedure in which it is used.

D. A temporary dental service will be considered an integral part of a complete service rather than a separate service, and separate payment will not be made for a temporary service unless otherwise included as a covered service of this policy.

E. If a Covered Person transfers from the care of one (1) dentist to that of another dentist during a

course of treatment, Delta Dental will not pay for more than the amount it would have paid for had only one (1) dentist rendered all the dental services during each course of treatment. Delta Dental will not pay for duplication of dental services.

F. Even if your dentist has prescribed, recommended or provided the service, it does

not necessarily make the procedure eligible for benefits even though it is not expressly excluded in this Dental Coverage Policy. Regardless of dental or medical necessity, not all treatments and services recommended or performed by your dentist are covered benefits.

G. If you or any of your dependents have received free services by or through a public program,

Delta Dental will coordinate benefits based on submitted documentation.

H. When an alternate benefit allowance is given, the alternate procedure allowed is subject to the time limitations of the procedure benefited.

I. When a procedure is benefited, and then a new service is performed on the same tooth, it is

subject to the time limitations of the prior service; therefore, benefits will be reduced on the new service.

J. Sterilization fees are considered a component of any procedure in which it is used.

K. If a covered service is subject to a benefit waiting period and the treatment begins prior to the

completion of the waiting period, no benefit is allowed. Exclusions

A. Any service or procedure that is not described as a benefit of this Summary of Benefits or included in the Dental Coverage Booklet, including Orthodontia.

B. Injuries or conditions covered under Workers’ Compensation or Employer's Liability laws; services

provided by any government agency; or any services that are provided free except as pursuant to Title XIX of the Social Security Act.

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C. Any dental services to treat injuries or diseases caused by any form of civil disobedience or criminal act, or any injuries intentionally inflicted.

D. Dental and surgical services with respect to cosmetic surgery or dentistry for purely cosmetic reasons, including cosmetic work done on dentures.

E. A service or procedure that is not generally accepted by the American Dental Association and

Delta Dental’s processing policies or not performed in accordance with the laws of the State of Arizona; services provided by someone other than a dentist or licensed hygienist employed by a dentist; or services performed to treat any condition, other than an oral or dental disease, malformation, abnormality or condition as explained. This includes anything determined (by Delta Dental) not to be necessary for treating a dental condition, disease or injury.

F. A method of treatment that is more costly than is customarily provided. Benefits will be based on

the least expensive professionally accepted method of treatment. You must pay the rest of the dentist’s fee if a more expensive dental procedure is selected.

G. Specialized techniques including but not limited to precious metal for removable appliances,

precision attachments for partials or bridges, overdentures, overlays, implantology as well as procedures and appliances associated with the preceding procedures in addition to personalization and characterization.

H. Charges for any health care not specifically covered under this plan including hospital charges,

prescription drug charges, and laboratory charges or fees.

I. Pain relievers like nitrous oxide, conscious sedation, euphoric drugs, or injections.

J. Procedures, appliances or restorations that are necessary to alter, restore or maintain occlusion, including but not limited to: altering vertical dimension, replacing or stabilizing tooth structure lost by attrition, erosion, abrasion wear or bruxism, realignment of teeth, periodontal splinting, splinting, gnathologic recordings, equilibration, bite appliances or harmful habit appliances and/or other damage to either hard or soft tissues as a result of a device worn in a tongue or lip piercing is not a covered benefit.

K. Temporary dentures, other than those provided in this Summary of Benefits.

L. Direct diagnostic or surgical and non-surgical treatment procedure applied to body joints

or muscles, temporal mandibular joint (TMJ) or temporal mandibular disturbances (TMD).

M. Delta Dental will not pay for the following: any claim submitted more than twelve (12) months from the date of service or twelve (12) months after the termination of the policy, whichever comes first, or any adjustments to previously received claims, including submissions of additional information, submitted more than twelve (12) months from the initial payment date or initial date issue date of the requested information.

Additional Information

A. For a full list of exclusions, please refer to the Dental Coverage Booklet. B. The Summary of Benefits, in conjunction with your Dental Coverage Booklet, appeals packet and

application for coverage constitute your full Dental Coverage Policy.

http://www.deltadentalcoversme.com/

.

HIPAA2015

Delta Dental of Arizona Notice of HIPAA Privacy Practices

Your Information. Your Rights. Our Responsibilities.

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

Your Rights You have the right to:

• Get a copy of your health and claims records • Request a correction your health and claims records • Request confidential communication • Ask us to limit the information we share • Get a list of those with whom we’ve shared your information • Get a copy of this privacy notice • Choose someone to act for you • File a complaint if you believe your privacy rights have been violated

Your Choices You have some choices in the way that we use and share information as we:

• Answer coverage questions from your family or others involved in payment for your care • Provide relief in a disaster situation • Market our services • Contact you for fundraising efforts

Our Uses and Disclosures We may use and share your information as we:

• Help manage the health care treatment you receive • Run our organization • Pay for your health services • Administer your health plan • Help with public health and safety issues • Do research • Comply with the law • Respond to organ and tissue donation requests and work with a medical examiner or funeral

director • Address workers’ compensation, law enforcement, and other government requests • Respond to lawsuits and legal actions • Provide you with information about health-related benefits and services , including dental

insurance products This is a summary. For more information, please refer to the following pages.

HIPAA2015

Your Rights When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.

Get a copy of health and claims records

• You can ask to see or get a copy of your health and claims records and other health information we have about you. Ask us how to do this.

• We will provide a copy or a summary of your health and claims records, usually within 30 days of your request. We may charge a reasonable, cost-based fee.

Ask us to correct health and claims records

• You can ask us to correct your health and claims records if you think they are incorrect or

incomplete. Ask us how to do this. • We may say “no” to your request, but we’ll tell you why in writing within 60 days.

Request confidential communications

• You can ask us to contact you in a specific way (for example, home or office phone) or to send

mail to a different address. • We will consider all reasonable requests, and must say “yes” if you tell us you would be in

danger if we do not.

Ask us to limit what we use or share

• You can ask us not to use or share certain health information for treatment, payment, or our operations.

• We are not required to agree to your request, and we may say “no” if it would affect your care.

Get a list of those with whom we’ve shared information

• You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why.

• We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.

Get a copy of this privacy notice

You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.

HIPAA2015

Choose someone to act for you

• If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.

• We will make sure the person has this authority and can act for you before we take any action.

File a complaint if you feel your rights are violated

• You can complain if you feel we have violated your rights by contacting us using the information at the end of this document.

• You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1- 877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/.

• We will not retaliate against you for filing a complaint. Your Choices For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.

In these cases, you have both the right and choice to tell us to:

• Share information with your family, close friends, or others involved in payment for your care • Share information in a disaster relief situation

If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.

We never share your information for marketing purposes unless you give us written permission. We never sell personal information.

Our Uses and Disclosures How do we typically use or share your health information? We typically use or share your health information in the following ways.

Help manage the health care treatment you receive

We can use your health information and share it with professionals who are treating you.

Example: A doctor sends us information about your diagnosis and treatment plan so we can arrange additional services.

http://www.hhs.gov/ocr/privacy/hipaa/complaints/

HIPAA2015

Run our organization

• We can use and disclose your information to run our organization and contact you when necessary.

• We are not allowed to use genetic information to decide whether we will give you coverage and the price of that coverage. This does not apply to long term care plans.

Example: We use health information about you to develop better services for you.

Pay for your health services

We can use and disclose your health information as we pay for your health services.

Example: We share information about you with your dental plan to coordinate payment for your dental work.

Administer your plan

We may disclose your health information to your health plan sponsor for plan administration.

Example: Your company contracts with us to provide a health plan, and we provide your company with certain statistics to explain the premiums we charge.

How else can we use or share your health information? We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.

Help with public health and safety issues

We can share health information about you for certain situations such as:

• Preventing disease • Helping with product recalls • Reporting adverse reactions to medications • Reporting suspected abuse, neglect, or domestic violence • Preventing or reducing a serious threat to anyone’s health or safety

Do research

We can use or share your information for health research.

http://www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html

HIPAA2015

Comply with the law

We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law.

Respond to organ and tissue donation requests and work with a medical examiner or funeral director

• We can share health information about you with organ procurement organizations. • We can share health information with a coroner, medical examiner, or funeral director when an

individual dies.

Address workers’ compensation, law enforcement, and other government requests

We can use or share health information about you:

• For workers’ compensation claims • For law enforcement purposes or with a law enforcement official • With health oversight agencies for activities authorized by law • For special government functions such as military, national security, and presidential protective

services

Respond to lawsuits and legal actions

We can share health information about you in response to a court or administrative order, or in response to a subpoena.

Our Responsibilities • We are required by law to maintain the privacy and security of your protected health

information. • We will let you know promptly if a breach occurs that may have compromised the privacy or

security of your information. • We must follow the duties and privacy practices described in this notice and give you a copy of

it. • We will not use or share your information other than as described here unless you tell us we can

in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.

For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.

http://www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html

HIPAA2015

Changes to the Terms of this Notice

We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, on our web site, and we will mail a copy to you. This Notice is effective as of March 1, 2015.

Contact us: 5656 W. Talavi Boulevard, Glendale, AZ 85306.

Phone: (602) 938-3131 or (800) 352-6132,

Email: customerservice@deltadentalaz.com Website: www.deltadentalaz.com

mailto:customerservice@deltadentalaz.comhttp://www.deltadentalaz.com/

Nondiscrimination and Language Assistance Services

1

Delta Dental complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Delta Dental does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. Delta Dental provides free aids and services to people with disabilities to communicate effectively with us, such as: • Qualified sign language interpreters• Written information in other formats (large print, audio, accessible electronic

formats, other formats) Provides free language and service to people whoseprimary language is not English, such as:

• Qualified interpreters• Information written in other languagesIf you need these services, contact Delta Dental’s Customer Service at:1(888)899-3734, TTY: 711.If you believe that Delta Dental has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Compliance Manager, PO Box 103 Stevens Point, WI 54481, Ph: 1(715)344-6087, TTY: 711, Fx: (715) 344-9058 or by email at: compliance_wi@deltadentalwi.com. You can file a grievance in person or by mail, fax or email. If you need help filing a grievance, our Compliance Manager is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington DC 20201, 1-800-868-1019, 800537-7697 (TDD). Complaint forms are available athttp://www.hhs.gov/ocr/office/file/index.html.

Shqip (Albanian)

KUJDES: Nëse flitni shqip, për ju ka në dispozicion shërbime të asistencës gjuhësore, pa pagesë. Telefononi në 1-888-899-3734 (TTY: 711).

አማርኛ (Amharic)

ማስታወሻ: የሚናገሩት ቋንቋ ኣማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች፣ በነጻ ሊያግዝዎት ተዘጋጀተዋል፡ ወደ ሚከተለው ቁጥር ይደውሉ 1-888-899-3734 (መስማት ለተሳናቸው: 711).

ةيبرعلا(Arabic)

. بالمجان لك تتوافر اللغویة المساعدة خدمات فإن اللغة، اذكر تتحدث كنت إذا: ملحوظة ).3734-899-888-1: والبكم الصم ھاتف رقم(-711 برقم اتصل

Ikirundi (Bantu – Kirundi)

ICITONDERWA: Nimba uvuga Ikirundi, uzohabwa serivisi zo gufasha mu ndimi, ku buntu. Woterefona 1-888-899-3734 (TTY: 711).

বাংলা (Bengali)

ল�� ক�নঃ যিদ আপিন বাংলা, কথা বলেত পােরন, তাহেল িনঃখরচায় ভাষা সহায়তা পিরেষবা উপল� আেছ। েফান ক�ন ১-888-899-3734 (TTY: ১-711)।

(Burmese)

ែខ�រ (Cambodian)

្របយ័ត�៖ េបើសិន�អ�កនិ�យ ��ែខ�រ, េស�ជំនួយែផ�ក�� េ�យមិនគិតឈ� �ល គឺ�ច�នសំ�ប់បំេរ �អ�ក។ ចូរ ទូរស័ព� 1-888-899-3734 (TTY: 711)។

tsalagi gawonihisdi (Cherokee)

Hagsesda: iyuhno hyiwoniha [tsalagi gawonihisdi]. Call 1 – 888-899-3734 (TTY: 711)

繁體中文

(Chinese) 注意：如果您使用繁體中文，您可以免費獲得語言援助服

務。請致電 1-888-899-3734（TTY：711） Oroomiffa (Oromo)

XIYYEEFFANNAA: Afaan dubbattu Oroomiffa, tajaajila gargaarsa afaanii, kanfaltiidhaan ala, ni argama. Bilbilaa 1-888-899-3734 (TTY: 711).

Français (French)

ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le 1-888-899-3734 (ATS : 711).

Kreyòl Ayisyen (French Creole)

ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele 1-888-899-3734 (TTY: 711).

Deutsch (German)

ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 1-888-899-3734 (TTY: 711).

λληνικά (Greek)

ΠΡΟΣΟΧΗ: Αν μιλάτε ελληνικά, στη διάθεσή σας βρίσκονται υπηρεσίες γλωσσικής υποστήριξης, οι οποίες παρέχονται δωρεάν. Καλέστε 1-888-899-3734 (TTY: 711).

�જુરાતી

(Gujarati)

�ચુના: જો તમે �જુરાતી બોલતા હો, તો િન:�લુ્ક ભાષા સહાય

સેવાઓ તમારા માટ� ઉપલબ્ધ છે. ફોન કરો 1-888-899-3734 (TTY:711).

�हदं� (Hindi) ध्यान द�: य�द आप हिंदी बोलते ह� तो आपके िलए मुफ्त म� भाषा सहायता सेवाएं उपलब्ध ह�। 1-888-899-3734 (TTY: 711) पर कॉल कर�।

1-888-899-3734 (TTY: 711)

https://ocrportal.hhs.gov/ocr/portal/lobby.jsfhttp://www.hhs.gov/ocr/office/file/index.html

00000 041908.1 2

Hmoob (Hmong)

LUS CEEV: Yog tias koj hais lus Hmoob, cov kev pab txog lus, muaj kev pab dawb rau koj. Hu rau 1-888-899-3734 (TTY: 711).

Bahasa Indonesia (Indonesian)

PERHATIAN: Jika Anda berbicara dalam Bahasa Indonesia, layanan bantuan bahasa akan tersedia secara gratis. Hubungi 1-888-899-3734 (TTY: 711).

Italiano (Italian)

ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero 1-888-899-3734 (TTY: 711).

日本語

(Japanese) 注意事項：日本語を話される場合、無料の言語支援をご利用

いただけます。1-888-899-3734（TTY:711）まで、お電話にてご連絡ください

한국어(Korean)

주의: 한국어를 사용하시는 경우, 언어 지원 서비스를

무료로 이용하실 수 있습니다. 1-888-899-3734 (TTY: 711)번으로 전화해 주십시오.

èdè Yorùbá (Yoruba)

AKIYESI: Ti o ba nso ede Yoruba ofe ni iranlowo lori ede wa fun yin o. E pe ero ibanisoro yi 1-888-899-3734 (TTY: 711).

Igbo asusu (Ibo)

Ige nti: O buru na asu Ibo asusu, enyemaka diri gi site na call 1-888-899-3734 (TTY: 711).

ພາສາລາວ (Lao)

ໂປດຊາບ: ຖ້າວ່າ ທ່ານເວົ້າພາສາ ລາວ, ການບໍລິການຊ່ວຍເຫຼືອດ້ານພາສາ, ໂດຍບໍ່ເສັຽຄ່າ, ແມ່ນມີພ້ອມໃຫ້ທ່ານ. ໂທຣ 1-888-899-3734 (TTY: 711).

Diné Bizaad (Navajo)

D77 baa ak0 n7n7zin: D77 saad bee y1n7[ti’go Diné Bizaad, saad bee 1k1’1n7da’1wo’d66’, t’11 jiik’eh, 47 n1 h0l=, koj8’ h0d77lnih 1-888-899-3734 (TTY: 711.)

नेपाल�(Nepali)

ध्यान िदनहुोस:् तपाइ�ले नेपाली बोल्नहु�न्छ भने तपाइ�को िनिम्त भाषा सहायता सेवाह� िनःशलु्क �पमा उपलब्ध छ । फोन गनुर्होस ्1-888-899-3734 (�ट�टवाइ: 711) ।

Thuɔŋjaŋ (Nilotic – Dinka)

PIŊ KENE: Na ye jam në Thuɔŋjaŋ, ke kuɔny yenë kɔc waar thook atɔ̈ kuka lëu yök abac ke cïn wënh cuatë piny. Yuɔpë 1-888-899-3734 (TTY: 711)

Deitsch (Pennsylvania Dutch)

Wann du [Deitsch (Pennsylvania German / Dutch)] schwetzscht, kannscht du mitaus Koschte ebber gricke, ass dihr helft mit die englisch Schprooch. Ruf selli Nummer uff: Call 1-888-899-3734 (TTY: 711).

یسراف(Farsi)

شما رایب رایگان بصورت زبانی تسھیالت کنید، می گفتگو فارسی زبان بھ اگر: توجھ .بگیرید تماس (TTY: 711) 3734-899-888-1 با. باشد می فراھم

Polski (Polish)

UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer 1-888-899-3734 (TTY: 711).

Português (Portuguese)

ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para 1-888-899-3734 (TTY: 711).

ਪੰਜਾਬੀ

(Punjabi)

ਿਧਆਨ ਿਦਓ: ਜੇ ਤਸੁ� ਪੰਜਾਬੀ ਬੋਲਦ ੇਹੋ, ਤ� ਭਾਸ਼ਾ ਿਵੱਚ ਸਹਾਇਤਾ ਸੇਵਾ

ਤੁਹਾਡੇ ਲਈ ਮੁਫਤ ਉਪਲਬਧ ਹੈ। 1-888-899-3734 (TTY: 711) 'ਤੇ ਕਾਲ

ਕਰੋ।

Русский (Russian)

ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1-888-899-3734 (телетайп: 711).

Srpsko-hrvatski (Serbo-Croatian)

OBAVJEŠTENJE: Ako govorite srpsko-hrvatski, usluge jezičke pomoći dostupne su vam besplatno. Nazovite 1-888-899-3734 (TTY- Telefon za osobe sa oštećenim govorom ilisluhom: 711).

Español (Spanish)

ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-888-899-3734 (TTY: 711).

Kiswahili (Swahili)

KUMBUKA: Ikiwa unazungumza Kiswahili, unaweza kupata, huduma za lugha, bila malipo. Piga simu 1-888-899-3734 (TTY: 711).

ܣܼܘܸܪ݂ܬ (Assyrian)

ܚܬܘܿܢ ܐܸܢ: ܙܼܘܵܗܵܪܐ ܡܸܙܡܼܝܬܘܿܢ ܹܟܐ ܼܐܿ ܒܠܼܝܬܘܿܢ ܵܡܨܼܝܬܘܿܢ ،ܵܐܬܿܘܵܪܵܝܐ ܸܠܵܫܵܢܐ ܼܗܿ ܕܼܩܹܿܬܐ ܪܵܬܐ ܸܚܠܼܡܿ ܼܝܿ ܵܓܵܢܐܼܝܬ ܒܸܠܵܫܵܢܐ ܕܼܗܿ ܠ ܩܪܘܿܢ. ܼܡܿ 3734-899-888-1 ܸܡܢܵܝܵܢܐ ܼܥܿ

(TTY: 711) Tagalog (Tagalog – Filipino)

PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-888-899-3734 (TTY: 711).

ภาษาไทย (Thai) เรียน: ถา้คุณพดูภาษาไทยคุณสามารถใชบ้ริการช่วยเหลือทางภาษาไดฟ้รี โทร 1-888-899-3734 (TTY: 711).

خبردار: اگر آپ اردو بولتے ہیں، تو آپ کو زبان کی مدد کی خدمات مفت (Urdu) اُرُدو .(TTY: 711) 3734-899-888-1میں دستیاب ہیں ۔ کال کریں

Українська (Ukrainian)

УВАГА! Якщо ви розмовляєте українською мовою, ви можете звернутися до безкоштовної служби мовної підтримки. Телефонуйте за номером 1-888-899-3734 (телетайп: 711).

Tiếng Việt (Vietnamese)

CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-888-899-3734 (TTY: 711).

Booklet - B0518.pdfA Simple Explanation of Your Dental InsuranceKey Terms and Fine Print You Need to KnowCommon Questions About Your PolicyDelta Dental PPO DentistsA. The dental office has agreed to accept the Delta Dental PPO contracted allowance for covered procedures.B. You pay for the applicable co-insurance, deductible, optional procedures and any services not covered by this policy.C. The dental office will complete the claim forms and submit to Delta Dental for payment, pre-determination or coordination of benefits.

Delta Dental Premier Dentists who are not Delta Dental PPO DentistsA. The dental office has agreed to accept the Delta Dental Premier contracted allowance for covered procedures.B. This plan bases payment for covered procedures on the Delta Dental PPO contracted allowance.C. You are responsible for the difference between the Delta Dental PPO contracted allowance and the Delta Dental Premier contracted allowance.D. You pay for the applicable co-insurance, deductible, optional procedures and any services not covered by this policy.E. The dental office will complete the claim forms and submit to Delta Dental for payment, pre-determination or coordination of benefits.F. In most instances, treatment from a Delta Dental Premier dentist will result in a reduced benefit when compared to a Delta Dental PPO dentist.

Out-of-Network Dentists who are not Delta Dental PPO or Delta Dental Premier DentistsA. The dental office has NOT agreed to accept Delta Dental’s allowance as payment in full.B. You are responsible for the difference between Delta Dental’s allowance and the full cost of treatment.C. You pay for the applicable co-insurance, deductible, optional procedures and any services not covered by this policy.D. You are responsible for the submission of the claim forms or the predetermination of benefits form to Delta Dental.E. Delta Dental will pay you directly for the amount of benefits payable. The benefits in This Dental Coverage Policy may not be assigned.F. In most instances, treatment from an Out-of-Network dentist will result in a reduced benefit when compared to a Delta Dental PPO dentist or Delta Dental Premier dentist.

A. You are responsible for the submission of the claim forms or the predetermination of benefits form to Delta Dental.B. The claim forms must include the billed charges in that country’s currency and a conversion fee into United States dollars.C. You are responsible for the submission of a copy of that dentist’s license to practice dentistry in the county where services were rendered.D. You are responsible to the Out-of-Network dentist for the full cost of treatment. Delta Dental will reimburse you for the amount of benefits payable by the plan. The benefits in this Dental Coverage Policy may not be assigned.E. The payment for services rendered is based on the lesser of the billed charges or Delta Dental’s Foreign Non-Participating Dentist Table of Allowance. You will be required to pay the difference between any amount billed by the dentist and Delta Den...

You have a 31-day grace period to pay your premium. You are still covered during the grace period. If you don’t pay your premium within the grace period, you will lose coverage on the last day of the grace period. You must pay for coverage provided du...

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