Pechanga 2013-2014 Benefits Guide

Dental Coverage

To help you manage dental costs, PR&C provides all full-time Team Members with two different dental plan options from which to choose, Delta Dental DHMO plan and Delta Dental DPPO plan. Both options provide coverage for preventive, basic, major and orthodontia services. Similar to a medical HMO, the Delta Dental DHMO plan offers low out of pocket costs but only covers services from dental providers participating in the Delta Dental DHMO provider network, DeltaCare USA. You and your enrolled dependents must select a DHMO dentist/dental practice to manage your care. Delta Dental PPO Plan allows you to receive treatment from PPO network dentists/dental practices and take advantage of their fee discounts. The PPO provider network consists of Delta Dental PPO providers and Delta Dental Premier providers. PPO providers are contracted In-network providers while the Premier providers are contracted Out-of- network providers. The PPO Contracted Fees are calculated differently for each group so your costs will vary depending on the network you select. You also have the freedom to receive treatment from a non-network dentist, but you are responsible for any fees above the Delta Dental Program Allowance for those services. Locate participating Delta Dental providers at www.deltadentalins.com . Under the Dental Plan drop down menu, select DeltaCare USA for the DHMO plan. For the DPPO plan you can select Delta Dental PPO (for the greatest savings) or Delta Dental Premier. Review the plan comparison below to help determine which plan is right for your needs.

Delta Dental Plan Summaries

DHMO/DeltaCare USA

Delta Dental PPO

Benefit and Covered Services

In-Network ONLY

In-Network

Premier Network/Non-Network**

Deductible

None None

$50 per person, $150 per family

Calendar Year Max Benefit

$1,800 per person (not including preventive services costs and lifetime orthodontia maximum)

$1,800 per person (not including lifetime orthodontia maximum)

Preventive Services Cleanings, bitewing x-rays, exams, fluoride, sealants Basic Services Fillings, extractions, periodontics, endodontics Major Services Crowns, bridges, dentures, inlays, onlays & cast, implants

Fee schedule

No charge

You pay 10% of allowed charge*

Fee schedule

You pay 10% after deductible

You pay 30% of allowed charge* after deductible

Fee schedule

You pay 40% after deductible You pay 50% of allowed charge* after deductible

Orthodontia Adult and dependent child(ren) Fee schedule

You pay 50% up to $1,000/person/lifetime

You pay 50% of allowed charge* up to $600/person/lifetime

In-PPO Network

Out-of-PPO Network

Delta Dental PPO SM Dentists

Delta Dental Premier* Dentists & Non-Delta Dental Dentists

You will usually pay the lowest amount for services when you visit a Delta Dental PPO dentist. PPO dentists agree to accept a reduced fee for PPO Patients. You are charged only the patient's share* at the time of treatment. Delta Dental pays its portion direct to the dentist. PPO dentists will complete claim forms and submit them for you at no charge.

You are responsible for the difference between the amount Delta Dental pays and the amount your non-Delta Dental dentist bills. You will usually have the highest out-of- pocket costs when you visit a non-Delta Dental dentists. Premier dentists may not balance bill above Delta Dental's approved amount, so your out-of-pocket costs may be lower than with non-Delta Dental dentists' charges. Non-Delta Dental dentists may require you to pay the entire amount of the bill in advance and wait for reimbursement. Premier dentists charge you only the patient's share* at the time of treatment. You may have to complete and submit your own claim forms, or pay your non-Delta Dental dentist a service fee to submit them for you.** Premier dentists will complete claim forms and submit them for you at no charge.

* Patient's share is the coinsurance/copayment, any remaining deductible, any amount over the annual maximum and any services your plan does not cover. ** If you visit a non-network dentist, Delta Dental will send the benefit payment directly to you. You are responsible for paying the non-network dentist's total fee, which may include amounts in excess of your share of your plan's contract allowance.

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