Sacramento Area Electrical Workers
Trust Funds
The Delta Dental Premier plan allows you to:
• Visit any licensed dentist of your choice
• Change dentists at any time
• Go to a dental specialist of your choice
• Receive dental care anywhere in the world
Delta Dental Premier is a fee-for-service plan with freedom to choose any licensed dentist. The program pays a percentage for covered services; you may be charged only what we determine is the "patient share."
To use the plan, just call the dental office of your choice and make an appointment. During your first appointment, give your dentist your group number, which is at the lop of this page, and the primary enrollee's social security number.
For a list of Delta dentists in your area, search the denlisl directory on our web site at www.deltadentalca.org. You can also check with your benefits administrator, who has a complete list of Delta dentists.
Visit our web site to view your eligibility and benefits or print your own ID card. (Note: You do not need an ID card to verify coverage, make an appointment or receive treatment.) You also can have eligibility information faxed to you by calling toll-free (800) 765-6003.
| WHO'S COVERED | Primary enrollee and spouse as well as dependent children to age 19 and fulltimestudents to age 24 |
| DEDUCTIBLES ANDBENEFITS MAXIMUM | $50 per person, $150 per famity percalendar year. The maximum benefit paid per calendar year is $2,000 per person. |
DIAGNOSTIC AND PREVENTIVE BENEFITS* Oral examinations, biopsy, fluoride treatment, spacemaintainers, specialist consultations |
100% of Delta dentist's allowed fee (no deductible applies for thesecleanings, x-rays, examinations of tissue services) |
BASIC BENEFITS* oral surgery(extractions), tissue removal (biopsy),fillings, root canals, periodontic (gum)treatment, sealants |
80% of Delta dentist's allowed fee |
| CROWNS AND OTHER CAST RESTORATIONS* | 80% of Delta dentist's allowed fee |
PROSTHODONTIC BENEFITS* bridges, partial dentures, full dentures |
80% of Delta dentist's allowed fee |
ORTHODONTIC BENEFITS* for adults and dependent children |
80% of Delta dentist's allowed fee (subject to a$2,000 lifetime maximum per person) |
| *Please refer to your Evidence of Coverage for limitations on these benefits. Some examples of limitations on services ae the number of cleanings and oral exams covered in a calendar year, and time limitations on filIing and crown repIacements. Note: Delta dentists are paid on a different fee basis than non-Delta dentists. This may result in higher out-of-pocket costs to you when you visit a non-Delta dentist. | |