The Plan’s dental benefits are designed to help pay a portion of your dental expenses. Delta Dental, the nation’s largest and most experienced dental benefits carrier, provides the PPO network for the Plan.

Selecting a Dentist

There are two types of Dentists in the Delta Dental network:

• Delta Dental PPO Dentists
• Delta Premier Dentists

When you use a Delta Dental PPO Dentist, your diagnostic and preventive services are covered at 100% and are not subject to the Deductible. Payment is based on a pre-approved fee, and your Dentist will file your Claims for you.

When you use a Delta Premier Dentist, payment is based on a pre-approved fee. These Dentists will file your Claim forms for you, but diagnostic and preventive services are subject to the Deductible and paid at less than 100%.

To find a Delta Dental PPO or Delta Premier Dentist:

• Visit www.deltadentalins.com/sag-aftra.
• Call your Dentist and ask if he or she is a Delta Dental PPO Dentist or Delta Premier Dentist.

Using an Out-of-network Dentist

When you use a Dentist outside of Delta Dental’s network, or if you reside outside the United States, payment is based on the Plan’s Allowance or the fee the Dentist actually charges, if less. If your Dentist’s fees exceed the Plan’s Allowance, you are responsible for the difference between the Plan’s payment and the Dentist’s actual charges. In addition, you will be responsible for your regular Coinsurance and any Deductible that may apply. Finally, your out-of-network Dentist may collect payment up front and may not be willing to file a Claim form for you.

Deductible

Dental benefits are payable after you meet the annual Deductible. This dental Deductible is a separate Deductible from the Hospital, medical and prescription drug Deductibles. The amount of the dental Deductible differs for Plan I and Plan II, as noted below:

• Plan I - $75 per person/$200 per family.*
• Plan II - $100 per person/no family maximum.

If your eligibility changes from Plan I to Plan II during a calendar year, any charges that were applied toward your Plan I Deductible will apply toward your Plan II Deductible. If your eligibility changes from Plan II to Plan I, the reverse is also true.

*If two or more members of your family are injured in the same accident, only one Deductible will be applied against all the covered dental charges incurred during any one year as a result of such accident.

Dental Benefits

Covered dental charges are charges from a Dentist or Physician for the services and supplies required for dental care and treatment of a disease, defect or accidental injury – or for preventive dental care.

Covered dental charges do not include any amounts above the customary charges for similar services or supplies by Dentists or Physicians in the same area. Where alternative services or supplies are customarily available for such treatment, covered dental charges will only include the least expensive professionally acceptable treatment plan.

Charges must be incurred and the services and/or supplies furnished while you or your Dependent are covered by the Plan. Charges are incurred on the date the service is rendered or the supply is furnished, with the following three exceptions:

1. With respect to fixed bridgework, crowns, inlays, onlays or gold restorations, the charge is incurred on the first date of preparation of the affected tooth or teeth.
2. With respect to full or partial dentures, the charge is incurred on the date the impression is taken.
3. With respect to endodontics, the charge is incurred on the date the tooth is opened for root canal therapy.

As shown in the table above, the Plan pays a different percentage based on the type of dental services you receive.

Diagnostic and Preventive Services

Diagnostic and preventive services under the dental benefits include the following:

• Oral examination – Once every six months (an additional oral exam is available for women while they are pregnant).
• Cleanings – Two per calendar year (an additional cleaning/scaling is available for women while they are pregnant).*
• X-rays:
  • Bitewing – Once every six months;
  • Full mouth – Once every three years;
  • Panoramic – Once every three years.
• Fluoride treatment – Individuals under age 19, once per calendar year.
• Biopsy/tissue examination.
• Emergency palliative treatment.
• Consultation by a covered specialist.
• Space maintainers.
• Study models.
• Sealants – Individuals under age 14, once every three years.

Basic Services

Basic services under the dental benefits include the following:

• Restorative – Amalgam, silicate or composite fillings. Charges for fillings are payable when they are necessary to restore the structure of the tooth broken down by decay or non-accidental injury.
• Oral surgery – Extractions, including surgical removal of teeth.
• Endodontics – Root canal therapy
• Periodontics – Treatment of gums and bones supporting teeth.
• General anesthetics or IV sedation for oral surgery and certain endodontic and periodontal procedures.
• Injectable antibiotics.
• Addition of teeth to existing denture.
• Repair and rebasing of existing dentures.

Major Services

Major services under the dental benefits include the following:

• Restorative services – Gold fillings, inlays and crowns.
• Crown replacement – If crown is over three years old.
• Gold filling replacement – If filling is over five years old.
• Fixed bridges/partial or full dentures/implants – If required to replace lost natural teeth or an existing prosthesis or implant which is over five years old and cannot be made serviceable.

Major services are also subject to these additional limitations:

1. Covered charges for both temporary and permanent prostheses are limited to the charge for a permanent prosthesis.
2. Covered charges for a crown or gold filling will be limited to the charge for an amalgam filling, unless the tooth cannot be restored with amalgam.
3. Covered charges for porcelain or plastic veneer crowns (tooth colored crowns) may be limited to the charge for a metal crown on certain teeth in the back of the mouth. You may want to obtain a pretreatment estimate so you will know how much the Plan will pay.
4. Charges for gold fillings, inlays and crowns are payable when they are necessary to restore the structure of the tooth broken down by decay or non-accidental injury.
5. Implants (an artificial tooth root that a periodontist places into your jaw to hold a replacement tooth or bridge) are covered under the major services portion of the Plan’s dental benefits. Additional surgical procedures, such as bone grafting or tissue regeneration, or special imaging techniques such as CT scans, that are performed in connection with the placement of the implant are not covered under the dental or medical benefits. You may want to obtain a pre-treatment estimate so you will know how much the Plan will pay.

Maximum Dental Benefit

The maximum amounts that the Plan will pay for all covered dental charges in a calendar year are listed below:

• Plan I - $2,500 per person.
• Plan II - $1,000 per person.

There is no calendar year maximum for covered individuals under age 19.

If your eligibility changes from Plan I to Plan II during a calendar year, any charges that were applied toward your Plan I annual maximum will apply toward your Plan II annual maximum. If the Plan has already paid more than $1,000 under your Plan I eligibility, no additional dental benefits will be paid under your Plan II eligibility for the rest of the calendar year.

If your eligibility changes from Plan II to Plan I in a calendar year, any charges that were applied toward your Plan II annual maximum will apply toward your Plan I annual maximum.

Pre-treatment Estimates

The Plan’s dental benefits include an optional provision that allows you to learn in advance how much the Plan will pay for extensive dental work – before services are performed. The Plan strongly suggests that you ask your Dentist to request a free pre-treatment estimate from Delta Dental before undergoing any major services, or even basic services (see above). This will ensure that you know up front what the Plan will pay and the amount for which you will be responsible. For information on how to request a pre-treatment estimate, please refer to the section on filing a Claim.

Questions

If you need help or have any questions, you can call the Plan or contact Delta Dental by visiting www.deltadentalins.com/sag-aftra or calling (800) 846-7418.

Non-covered Dental Expenses

• Accidental injury to natural sound teeth. (This coverage is provided under the medical benefits.)
• Anesthesia, other than anesthesia or IV sedation administered by a licensed Dentist in connection with covered oral surgery and select endodontic and periodontal procedures.
• Extra-oral grafts (grafting tissues from outside the mouth to oral tissue).
• Hospital costs and any additional fee charged by the Dentist for Hospital treatment.
• Occlusal guards and complete occlusal adjustment.
• Orthodontic treatment other than for related extractions or space maintainers.
• Procedures, restorations and appliances to increase vertical dimension or to restore occlusion.
• Replacement of existing restorations for any purposes other than active tooth decay.
• Services with respect to congenital or developmental malformations, or services and supplies cosmetic in nature, including but not limited to cleft palate, upper or lower jaw malformations, enamel hypoplasia (lack of development), fluorosis (discoloration of the teeth) and anodontia (congenitally missing teeth).
• Services and supplies not recognized as generally accepted dental practice.
• Services for restoring tooth structure lost from wear, for rebuilding or maintaining chewing surfaces due to teeth out of alignment or occlusion, or for stabilizing the teeth, including but not limited to equilibration and periodontal splinting.
• Specialized techniques involving precision attachments, personalization or characterization.
• Surgery or special imaging performed in connection with the placement of a dental implant.
• Training in or supplies used for dietary counseling, oral hygiene or plaque control.
• Temporomandibular joint syndrome (TMJ) treatment. (In certain circumstances, this coverage may be provided under the medical benefits.)
• Treatment by someone other than a Dentist or Physician, except when performed by a duly qualified technician under the direction of a Dentist or Physician.

For additional information, refer to the general exclusions.