Group Dental Program

DENTAL BENEFIT PLAN SUMMARY

Welcome to Delta Dental, one of the nation’s leaders in dental care programs.

Our organization is a service corporation sponsored by the Idaho dental profession with our major concern being you and your continuing dental health.  

This booklet only summarizes your dental coverage and does not constitute a contract. The Benefits Endorsement page lists the benefits which your employer has selected for your plan. Full terms and conditions are set forth in a contract between your employer and Delta Dental Plan of Idaho which is on file with your employer.  

TABLE OF CONTENTS

BENEFITS ENDORSEMENT PAGE ---------------------------------------------------3

DEFINITIONS ---------------------------------------------------------------------------------4

            Benefits ---------------------------------------------------------------------4

            Benefit Maximums ----------------------------------------------------------4

            Categories of Benefits ------------------------------------------------------4

                        Diagnostic  ---------------------------------------------------------4

                        Preventive  ---------------------------------------------------------4

                        Basic --------------------------------------------------------------4

                        Major Services  ----------------------------------------------------4

                        Orthodontic --------------------------------------------------------4

            Coverage Year -------------------------------------------------------------4

            Deductible -----------------------------------------------------------------4

            Usual, Customary and Reasonable (UCR) ---------------------------------4

                        Usual ------------------------------------------------------------- 4

                        Customary -------------------------------------------------------- 4

                        Reasonable --------------------------------------------------------4

BENEFITS ENDORSEMENT PAGE

Mountain Adventures

GROUP # 5555

  * * GROUP BENEFITS SELECTED * *

DIAG. AND PREVENTIVE SERVICES                             100%

   (Deductible is not applicable to Diag.

    and Preventive services)

BASIC SERVICES                                                                80%

MAJOR SERVICES                                                              50%

BENEFIT MAX. PER CALENDAR YEAR                       $1,250

DEDUCTIBLE

     - PER PERSON                                                                 $25

     - FAMILY MAXIMUM                                                    $75

           No family shall be obligated to satisfy more than

           Three (3) separate deductibles each calendar year.

ORTHODONTIC SERVICES                                               50%

ORTHODONTIC MAX. BENEFIT                                  $1,000

ORTHODONTIC WAITING PERIOD                                 N/A

Delta Dental Plan of Idaho, Inc.

P.O. Box 2870

Boise, Idaho 83701

(208) 344-4546

FAX (208) 344-4649

DEFINITIONS

Certain words that you will see in this booklet have specific meanings. These definitions should make your dental program easier to understand.

Benefits – those dental services available under the Contract.

Benefit Maximums – the maximum amount payable for each covered individual per calendar year.  

Categories of Benefits:

Diagnostic – procedures to help the dentist evaluate your dental health to determine necessary treatment.

Preventive – procedures to prevent dental disease (cleanings, for example)

Basic – procedures necessary to restore the teeth (other than crowns or cast restorations), oral surgery, endodontic (root canals) and periodontic (gum) procedures.

Major Services – crowns, veneers, onlays, procedures involving bridges and dentures to replace missing teeth.

Orthodontic – procedures involving appliances (such as braces) or surgery to realign teeth and/or jaw which otherwise do not function properly.  

Coverage Year – a coverage year is a calendar year in which deductibles and benefit maximums apply.

Deductible – the amount payable per covered individual per calendar year.

Usual, Customary and Reasonable (UCR):

Usual – a “usual” fee would be a fee usually charged for a given service by an individual dentist to all his/her patients, i.e., his/her own usual fee.

Customary – a fee is “customary” when it is within the range of usual fees charged by dentists of similar training and experience for the same service within that same specific and limited geographic area.

Reasonable – a fee is “reasonable” when it meets with the above two criteria and is justifiable considering the circumstances of the particular case in question.