Dental

Dental Plan - Delta Dental of Idaho

October 1, 2002 - September 30, 2003

MEDICAL DENTAL VISION LIFE/AD&D LTD STD FLEX EAP

Information provided is in summary format. Any difference between the summary provided and actual contract will be settled in favor of the contract.

Point of Services (POS) Dentists

Participating/Non-Participating Dentists*

Deductible

N/A
N/A

Preventive

    100%**
         70-100%***

Basic

       80-100%**
         70-100%***

Major

         55%
           50%****

Annual Maximum

$1,000

Dependent Age Limit

To age 23

Predetermination Recommended For:

Services of $200 or more

Orthodontia

Not covered

*Payment for services provided by non-participating dentists is based on actual charges, or the usual and customary charges in Idaho, whichever is less. You are responsible for any remaining balance.

**The benefit payment increases 10% each calendar year of enrollment up to 100%, provided the insured receives services each calendar year. If an insured does not receive services in a given calendar year, the benefit payment decreases 10% for the next calendar year, but will never go below 80%.

***The benefit payment increases 10% each calendar year of enrollment up to 100%, provided the insured receives services each calendar year. If an insured does not receive services in a given calendar year, the benefit payment decreases 10% for the next calendar year, but will never go below 70%.

****You must be employed as a full-time equivalent employee for twelve (12) months prior to receiving benefits for major services.

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