---

There are two dental plans to choose from – the Metropolitan Life Plan (MetLife) and the Delta Dental Plan of Tennessee (Delta Dental).  You may elect either plan, but not both. 

The dental plans pay benefits to you and your covered dependents for a wide range of dental services and supplies, including preventive, diagnostic, restorative, prosthodontic and orthodontic care.

Your Dental Plans …

... Encourage Preventive Care The dental plans promote regular dental care by covering preventive and diagnostic services, such as routine checkups, cleanings and X-rays, at 100% of Reasonable and Customary Charges with no deductible. ... Offer Protection for More Extensive Treatment Oral surgery, restorative and prosthodontic services are covered after you meet the annual deductible. ... Provide Orthodontic Benefits for Your Children Coverage for orthodontic treatment is available for your Eligible Dependent Children under age 24.

What happens to your benefits when ... For more information about what happens to your dental benefits when certain changes or events occur, see “How Changes Affect Your Benefits” in the “About Your Benefits” section. For more information about coverage you and your Eligible Dependents may be eligible to continue in certain cases when coverage would otherwise end, refer to COBRA within the “Administrative Information” section.

Some facts to remember about your dental plans ...

Dependents in military service are not eligible for dental coverage. These plans do not cover services outside the United States. Dental coverage may not be converted to individual coverage.  This information is a summary of the dental benefits under the plans.  Should there be a conflict between the summary and the group contract, the group contract will control.  A predetermination of benefits is recommended for costs that are expected to exceed $100.

Administrative Information Information about the administration of your dental plans can be found in the section entitled “Administrative Information.”

---

MetLife Dental Plan

You select and schedule an appointment with the provider of your choice.  You are not required to use a network provider.  There is a difference in how a network provider versus a non-network provider bills for their services. 

Network Provider
MetLife has a Preferred Dentist Program (PDP) network.  Participating dentists agree to accept a discounted fee schedule as full payment for covered service.  You will not be billed for any covered charges that are greater than the contracted fee schedule if you use a PDP provider. 

The PDP network is not available to hourly employees until January 1, 2007. 

Non-Network Provider

The Plan pays benefits to non-network providers based on “Reasonable and Customary Charges”

If you use a provider that is not part of the contracted PDP network, the plan pays benefits toward covered dental expenses on the basis of “Reasonable and Customary Charges.”
 
If you incur charges that exceed what is considered Reasonable and Customary, the plan covers the Reasonable and Customary Charge and you are responsible for paying the balance.  Charges beyond Reasonable and Customary will not count toward the deductible.

Briefly, the plan covers four types of dental services:

• Type A – Preventive and diagnostic services
• Type B – Oral surgery and restorative services
• Type C – Prosthodontic services
• Type D – Orthodontic services.

The plan pays different benefits for each of these types of coverage – with one annual deductible required for Type B and Type C services only.

Annual Deductible
You and each covered dependent must satisfy a $50 individual deductible each calendar year before benefits become payable toward Type B (oral surgery and restorative) services and Type C (prosthodontic) services covered by the plan.  The deductible does not apply to Type A (preventive and diagnostic) or Type D (orthodontic) services. 

Maximum Benefits
The plan pays up to a maximum of $1,500 per year and $20,000 ($10,000 for hourly employees until January 1, 2007) in a lifetime for each covered person for Type A, Type B, and Type C expenses combined.  For Type D (orthodontic) services, there is a separate lifetime maximum of $1,500 in benefits for each covered person.

Four Types of Dental Services Type A:    Preventive and diagnostic services Type B:    Oral surgery and restorative services Type C:    Prosthodontic services Type D:    Orthodontic services

MetLife Dental Plan
Refer to the "Covered Expenses" section, provided on the following page, for details.
Services Covered	Amount of Coverage*
Calendar Year Maximum	$1,500
Lifetime Orthodontic Maximum	$1,500
Lifetime Maximum	Salaried Employees and Retirees: $20,000 Hourly Employees: $10,000 until January 1, 2007 then $20,000
Annual Deductible (applies to Type B and Type C services)	$50 per member
Services Covered	Amount of Coverage*
TYPE A – Preventive and Diagnostic Services:
Oral Examinations	Covered 100%, once every 6 months
Prophylaxis (cleanings)	Covered 100%, once every 6 months
Full mouth X-rays	Covered 100%, once every 24 months
Bite-wing X-rays	Covered 100%, one set every 6 months
Fluoride	Covered 100% under age 19
Space Maintainers	Covered 100%
TYPE B – Oral and Restorative Services:
Fillings (other than gold), general anesthesia, occlusal guards, extractions and oral surgery*, periodontics, endodontics (root canal therapy)	Covered 80% after deductible
Sealants	Not covered
TYPE C – Prosthodontic Services (no age limit for bridges, partial dentures, or full dentures)	Covered 50% after deductible
TYPE D – Orthodontic Services: braces, surgical repositioning to correct malocclusion, surgical extractions, X-rays, retention checking	Covered 50% for dependents up to age 24
*Reasonable and Customary Charges apply for non-network providers.  The PDP network fee schedule applies for PDP providers.

Type A – Preventive and Diagnostic Services
The dental plan pays 100% of covered expenses for Type A (preventive and diagnostic) services, with no deductible required.

Covered expenses for preventive and diagnostic services include Reasonable and Customary Charges for:

• oral examinations (once every six months)
• cleaning and scaling of teeth (once every six months)
• bitewing X-rays (one set every six months)
• full mouth X-rays (one set every 24 months)
• topical fluoride applications for Children under age 19 (once every six months)
• space maintainers
• emergency treatment.

Type B – Oral Surgery and Restorative Services
After the deductible has been satisfied, the plan pays 80% of covered expenses for Type B (oral surgery and restorative) services.

Covered expenses for oral surgery and restorative services include Reasonable and Customary Charges for:

• amalgam fillings (charges for precious metals such as gold and for castings are considered based on Reasonable and Customary Charges for amalgam fillings)
• treatment of gum disease (periodontics)
• endodontic treatment, including root canal services
• extractions (except in connection with orthodontic treatment)
• oral surgery
• general anesthesia when determined necessary under the plan’s dental provisions.

Type C – Prosthodontic Services
After the deductible has been satisfied, the plan pays 50% of covered expenses for Type C (prosthodontic) services.

Covered expenses for prosthodontic services include Reasonable and Customary Charges for:

• inlays, onlays, crowns, and gold fillings
• fixed bridgework installed for the first time to replace missing natural teeth, including inlays and crowns as abutments, but excluding periodontal splinting
• full or partial dentures installed for the first time to replace missing natural teeth and adjacent structures and any adjustments required during the six-month period following installation
• repair or recementing of crowns, inlays, onlays, dentures, or bridgework
• replacement or modifications of dentures or bridgework if required:

• to replace one or more teeth extracted after the existing denture or bridgework was installed
• to replace an existing appliance which is at least five years old and cannot be made serviceable
• to replace a temporary denture that cannot be made permanent and has been in place 12 months or less.

Type D – Orthodontic Services
No deductible applies to Type D covered expenses.
 
All covered Children through age 23 are eligible to receive benefits for orthodontic services.  At age 24, all coverage under the plan ends, even if a course of orthodontic treatment is ongoing.

The plan payment for covered expenses (initial and monthly) is based on a schedule of allowances for non-network providers.  This schedule is available from the Benefit Plans Office.  A PDP network provider is paid based on the PDP fee schedule. 

Covered expenses for orthodontic services include charges for:

• braces
• surgical repositioning of the jaw, facial bones and/or teeth to correct malocclusion
• surgical extractions
• X-rays
• retention checking.

The MetLife Dental plan does not cover certain expenses, including but not limited to charges for:

• services provided before plan coverage becomes effective
• services other than those specifically covered by the plan
• services and supplies that are not provided by a legally licensed dentist or physician (or a licensed hygienist for the scaling or cleaning of teeth and topical application of fluoride under the dentist’s supervision)
• services or supplies that are cosmetic in nature, including charges for personalization or characterization of dentures
• replacement of a lost, missing, or stolen prosthetic device
• services covered by any workers’ compensation laws or employer’s liability laws, or services which an employer is required by law to furnish in whole or in part
• services rendered through a medical department, clinic, or similar facility provided or maintained by the patient’s employer
• services or supplies for which a covered person would not legally have to pay if there were no coverage
• services or supplies which do not meet accepted standards of dental practices, including charges for services or supplies which are unnecessary or experimental in nature
• services or supplies received as a result of dental disease, defect or injury due to an act of war, whether declared or not
• dental services or supplies that are payable by any government
• any duplicate prosthetic devices or sealants (material, other than fluorides, painted on the grooves of the teeth in an attempt to prevent future decay), oral hygiene, and dietary instruction
• plaque control programs
• implantology (an insert set firmly or deeply into or onto the part of the bone that surrounds and supports the teeth)
• periodontal splinting
• myofunctional therapy.

Expenses incurred for any of the services or supplies listed above may not be used to satisfy your deductible.

If your coverage ends because your employment terminates, you retire, or you lose eligibility, benefits for covered expenses incurred before your termination remain payable under the plan.

If you are undergoing a course of treatment when your coverage ends, benefits are payable for most covered charges related to that treatment and incurred up to 30 days after your termination.

Exceptions to this 30-day extension include treatment involving:

• prosthetic devices – impressions and tooth preparation must be completed before coverage ends and the device must be installed or delivered within two calendar months following the end of coverage

• crowns – tooth preparation must be completed before the coverage ends and the crowns installed within two calendar months following the end of coverage

• root canal therapy – the tooth must be opened before coverage ends and treatment completed within two calendar months following the end of coverage

• orthodontia – not extended, under any circumstance.

When you or your covered Eligible Dependents require dental care and treatment, you should discuss in advance with your dentist what needs to be done and how much it will cost.  If treatment is expected to cost $100 or more, you should ask your dentist to file for predetermination of benefits.  This helps you avoid surprises by letting you know how much is payable for the proposed treatment before it begins.

Here is how it works:

• Your dentist submits the proposed course of treatment to MetLife by itemizing services and charges on a regular claim form.
• MetLife then determines the amount the plan will pay and informs you and your dentist by sending each of you a “Notice of Benefits Allowable” statement.
• You are free to pursue any treatment; however, the plan may only pay for the treatment that is indicated on the "Notice of Benefits Allowable."

Whether or not you request predetermination of benefits, MetLife will pay the claim based on whatever information it has about your treatment.

If, according to generally accepted professional standards of dental practice, there is more than one suitable procedure for the treatment of a dental condition, the plan will pay benefits for the least expensive procedure that can be used for the effective treatment of that condition.  MetLife determines the benefit reimbursement amount when alternative courses of treatment are available.

If you and your dentist elect to use a more expensive procedure or material than the one determined to be appropriate by MetLife, you will be required to pay the difference between the dentist’s bill and the costs covered by the plan.

The plan does not cover treatment received before your insurance becomes effective.  However, if a course of treatment is started before the effective date and completed after the effective date, part of

the cost may be covered.  MetLife will determine whether a portion of the dentist’s fee can be allocated to treatment received after the effective date and covered under the plan.

You should file a claim whenever you and your covered Eligible Dependents incur covered dental expenses.  Claim forms are available from the Benefit Plans Office.  Claims must be filed no later than 90 days after the plan year in which the services were rendered.

Completed forms should be mailed to MetLife at the address listed on the claim form.

MetLife will send an explanation of payment with the benefit check.  If you have authorized MetLife pay your dentist directly, the dentist will receive an explanation of payment with the check, and you will receive a copy of the explanation.

The dental plan has a Coordination of Benefits (COB) provision that is designed to prevent duplication of payments when a person can collect benefits from more than one employer group dental plan.         

Under this provision, when coverage is provided both by the Company and another employer group plan, you can receive up to 100% of your covered expenses from both plans, but no more than that.

If you have an accidental injury, seek recommended care through your medical plan’s primary care physician to receive in-network benefits.  Treatment of injuries to your natural teeth by a dentist, physician or surgeon is covered under your medical coverage as long as services are provided within 12 months of the accident.

File your medical claim with your medical plan.  Claim must be filed no later than 90 days after the plan year in which services were rendered.

Dental benefits payable under a Company medical plan will reduce your benefits otherwise payable under the dental plan.  After you receive notice of payment from the medical plan, you should submit the notice of payment to MetLife. 

---

Delta Dental Plan

Eligibility and Enrollment
A subscriber or dependent who drops their coverage, but who still meets all eligibility requirements of the plan, may re-enroll during the first Open Enrollment period after having been out of the plan for 12 consecutive months. 

For further definitions of Eligible Employees, Eligible Dependents, and the term Child(ren), refer to the “Glossary” and “About Your Benefits” sections.

Choosing a Dentist
Delta Dental does not directly provide dental services and therefore is not liable for a dentist’s refusal to provide services.  It has contracted with “Participating Dentists.”  These dentists are independent contractors who have agreed to accept certain fees for the service they provide to you.  Dentists that have not contracted with Delta Dental are referred to as “Non-Participating Dentists.”

Although you are free to choose any dentist, your out-of-pocket expenses may be less if you choose a Participating Dentist.  Therefore, you should always ask your dentist if he is a Participating Dentist or verify with Delta Dental that your dentist is a Participating Dentist before receiving any dental services.

Participating vs. Non-Participating
A Participating Dentist’s charges are paid based on Delta Dental’s maximum fee schedule, which providers agree to accept, with no balance billing.  This is the Maximum Plan Allowance (“MPA”). 

You are responsible for charges exceeding the MPA if you go to a Non-Participating Dentist.  The MPA charges are based on fees charged in your geographic area.  For example, non-participating providers are generally reimbursed at the 51st percentile of Delta Dental’s prevailing fee schedule as submitted by all providers (based on an overall scale of 100, the maximum payment is paid at or below the 51st percentile).

Annual Deductible
You and each covered dependent must satisfy a $50 individual deductible each calendar year before benefits become payable toward Type B (basic) services and Type C (major) services covered by the plan. There is no deductible for Type A (preventive and diagnostic) services or Type D (orthodontic services).

Maximum Benefits
The plan pays up to a maximum of $1,500 per year for each covered person for Type A, Type B, and Type C expenses combined.  There is no lifetime maximum limit for Type A, Type B, and Type C covered expenses.  For Type D (orthodontic) services, there is a separate lifetime maximum of $1,500 in benefits for each covered person.

Emergency Dental Care
If you require emergency dental care, you may seek services from any dentist.  Your out-of-pocket expenses may be less if you choose a Participating Dentist. 

Four Types of Dental Services Type A:    Preventive and diagnostic benefits Type B:    Basic Benefits Type C:    Major Benefits Type D:    Orthodontic services The Delta Dental plan pays different benefits for each of these types of coverage – with an annual deductible required for Type B and Type C services only.

Delta Dental Plan – Summary of Benefits
Refer to the "Schedule of Benefits" section, provided on the following pages, for details.
Services Covered	Amount of Coverage
Calendar Year Maximum	$1,500
Lifetime Orthodontic Maximum	$1,500
Lifetime Maximum	N/A
Annual Deductible (applies to Type B and Type C services only)	$50 per member
Services Covered	Amount of Coverage
TYPE A – Preventive and Diagnostic Services:
Oral Examinations	Covered 100%, twice every 12 months
Prophylaxis (cleanings)	Covered 100%, twice every 12 months
Full mouth X-rays	Covered 100%, once every 3 years
Bite-wing X-rays	Covered 100%, two sets every 12 months
Fluoride	Covered 100% under age 19
Space Maintainers	Covered 100% under age 15
TYPE B – Basic Services:
Fillings (other than gold), general anesthesia, occlusal guards, extractions and oral surgery, periodontics, endodontics (root canal therapy)	Covered 80% after deductible
Sealants	Covered 80% under age 16, one benefit per tooth.  Chewing surfaces for permanent first and second molars only.
TYPE C – Major Services (no age limit for bridges, partial dentures, or full dentures)
Crowns	Covered 50% after deductible.
Bridges	Covered 50% after deductible, excluding porcelain, gold or veneer crowns for Children under age 12
Partial Dentures/Full Dentures	Covered 50% after deductible, excluding fixed bridges or cast partials for Children under age 16
TYPE D – Orthodontic Services: braces, surgical repositioning to correct malocclusion, surgical extractions, X-rays, retention checking	Covered 50% for dependents up to age 24

In addition to the limitations and exclusions listed in this “Schedule of Benefits” section, the “General Limitations and Exclusions” section also applies. 

Type A – Preventive and Diagnostic Services

1. Preventive – prophylaxis (cleaning), topical application of fluoride, and space maintainers.
2. Diagnostic – oral examination and X-rays to aid the dentist in planning required dental treatment.

Limitations and Exclusions on Preventive and Diagnostic Benefits

1. Two oral exams and cleanings, to include periodontal maintenance procedures, in any 12-month period.
2. Full mouth X-rays are covered once within 3 years, unless special need is shown.
3. Two sets of bite-wing X-rays in a 12-month period.
4. Topical application of fluoride for members up to 19 years of age.
5. Adult prophylaxis for members under 14 years of age is not allowed.
6. Space maintainers for members more than 14 years of age are not allowed.

Type B – Basic Benefits

1. Oral Surgery – extractions and other surgical procedures (including pre- and post operative care).
2. General Anesthesia & I.V.  Sedation – only when administered by a properly licensed dentist in a dental office in conjunction with covered surgery procedures or when necessary due to concurrent medical conditions.
3. Endodontia – treatment of the dental pulp (root canal procedures).
4. Periodontia – treatment of the gums and bones that surround the tooth.
5. Denture Repairs – services to repair complete or partial dentures.
6. Basic Restorations – amalgams (silver fillings) composites (white fillings) and prefabricated stainless steel crown restorations for the treatment of decay. 
7. Sealants – resin filling used to seal grooves and pits on the chewing surface of permanent molar teeth.
8. Occlusal guards.

Limitations and Exclusions on Basic Benefits

1. Restorative benefits are allowed once per surface in a 24-month period, regardless of the number or combinations of procedures requested or performed.
2. Payment for root canal treatment includes charges for X-rays and temporary restorations.  Root canal treatment is limited to once in a 24-month period by the same dentist or dental office.
3. Payment for periodontal surgery shall include charges for three months postoperative care and any surgical re-entry for a three-year period.  Root planing, curettage and osseous surgery are not a benefit for members under 14 years of age.
4. The replacement, by the same dentist or dental office, of amalgam or composite restorations within 24 months is not a benefit.
5. The replacement of a stainless steel crown on a primary tooth by the same dentist or dental office within a 24-month period of the initial placement is not a benefit.
6. The replacement of a stainless steel crown on a permanent tooth by the same dentist or dental office within a 60-month period of the initial placement is not a benefit.
7. Gold foil restorations are an Optional Service.
8. Porcelain, composite, and metal inlays are Optional Services.
9. A sealant is a benefit only on the unrestored, decay free chewing surface of the maxillary (upper) and mandibular (lower) permanent first and second molars.  Sealants are only a benefit on members under 16 years of age.  Only one benefit will be allowed for each tooth within a lifetime.

Type C – Major Benefits

1. Cast Restorations – Crowns and onlays are benefits for the treatment of visible decay and fractures of hard tooth structure when teeth are so badly damaged that they cannot be restored with amalgam or composite restorations.
2. Prosthodonics – Procedures for construction of fixed bridges, partial or complete dentures and repair of fixed bridges.
3. Complete or Partial Denture Reline – Chair side or laboratory procedure to improve the fit of the appliance to the tissue (gums).
4. Complete or Partial Denture Rebase – Laboratory replacement of the acrylic base of the appliance.

Limitations and Exclusions on Major Benefits

1. Replacement of crowns or cast restorations received in the previous five years is not a benefit.  Payment for cast restorations shall include charges for preparations of tooth and gingiva, crown build-up, impression, temporary restoration and any re-cementation by the same dentist within a 12-month period.
2. A cast restoration on a tooth that can be restored with an amalgam or composite restoration is not a benefit.
3. Procedures for purely cosmetic reasons are not benefits.
4. Porcelain, gold or veneer crowns for Children under 12 years of age are not a benefit.
5. Replacement of any fixed bridges, or partial or complete dentures, that the member received in the previous five years is not a benefit. 
6. Payment for a complete or partial denture shall include charges for any necessary adjustment within a six-month period.  Payment for a reline or rebase of a partial or complete denture is limited to once in a three-year period and includes all adjustments required for six months after delivery.
7. Payment for standard dentures is limited to the maximum allowable fee for a standard partial or complete denture.  A standard denture means a removable appliance to replace missing natural, permanent teeth.  A standard denture is made by conventional means from acceptable materials.  If a denture is constructed by specialized techniques and the fee is higher than the fee allowable for a standard denture, the patient is responsible for the difference.
8. Payment for implants (artificial materials implanted into or on bone or gums) or their removal is not a benefit.  However, an allowance for a standard complete or partial denture toward the cost of replacing multiple missing teeth will be made.  For single tooth implants, Delta Dental will make an allowance for a crown but not for the placement of the implant.
9. Payment for fixed bridges or cast partials for Children under 16 years of age is not a benefit.
10. A posterior bridge where a partial denture is constructed in the same arch is not a covered benefit.
11. Temporary partial dentures are a benefit only when upper anterior teeth are missing.

Type D – Orthodontic Services
Delta Dental will pay benefits for procedures using appliances to treat poor alignment of teeth and/or jaws.  Such poor alignment must significantly interfere with function to be a benefit.

Limitations and Exclusions on Orthodontic Benefits

1. Orthodontic benefits are limited to Eligible Dependent Children to age 24. 
2. Delta Dental shall make regular payments for orthodontic benefits.
3. If orthodontic treatment began prior to enrolling in this plan, Delta Dental will begin benefits with the first payment due the orthodontist after the subscriber or covered Eligible Dependent becomes eligible.
4. Benefits end with the next payment due the dentist after loss of eligibility or immediately if treatment stops. 
5. Benefits are not paid to repair or replace any orthodontic appliance received.
6. Orthodontic benefits do not pay for extractions or other surgical procedures.  However, these additional services may be covered under Preventive and Diagnostic or Basic Benefits.

Orthodontic Payment Method

1. The initial payment (initial banding fee) made by Delta Dental for comprehensive treatment will be 33% of the total fee for treatment subject to your copayment percentage and lifetime maximum.
2. Subsequent payments will be issued on a regular basis for continuing active orthodontic treatment.  Payments will begin in the month following the appliance placement date and are subject to your copayment and lifetime maximum. 

You may get an estimate of the cost of certain dental procedures before they are done.  This estimate is referred to as a predetermination.  You may have your dentist send Delta Dental a claim form detailing the projected treatment and Delta Dental will give an estimate of the benefits to be paid.  This will let you

know approximately how much the work will cost and what your share of the costs will be.  A predetermination is not a guarantee of payment.  Actual benefit payments will be based upon procedures completed and will be subject to continued eligibility along with plan limitations and maximums.

In cases where alternate or optional methods of treatment exist, Delta Dental will pay for the least costly professionally accepted treatment.  This determination is not intended to reflect negatively on the dentist’s treatment plan or to recommend which treatment should be provided.  It is a determination of benefits under the terms of the subscriber’s coverage.  The dentist and subscriber or dependent should decide the course of treatment. 

If the treatment rendered is other than the covered benefit, the difference between the Delta Dental allowance and the dentist’s fee, up to the approved amount, for the actual treatment rendered is due from the subscriber. 
For example, if your benefit plan allows for amalgams only even though a metal or porcelain inlay is suggested by your dentist, Delta Dental will pay for only the cost of the amalgam.

1. Participating Dentists will file your claim with Delta Dental.  If you need a claim form for services provided by a Non-Participating Dentist you may contact Delta Dental which will provide you with a claim form.  To be considered for benefits, a claim must be filed within 15 months of the date of service.
2. If you require emergency dental care, you may seek services from any dentist.  Your out-of-pocket expenses may be less if you choose a Participating Dentist. 
3. You may get an estimate of the cost of certain dental procedures before they are done.  This estimate is referred to as a predetermination.  You may have your dentist send Delta Dental a claim form detailing the projected treatment and Delta Dental will give an estimate of the benefits to be paid.  A predetermination is not a guarantee of payment.  Actual benefit payments will be based upon procedures completed and will be subject to continued eligibility along with plan limitations and maximums.
4. If you or your covered Eligible Dependent receive an injury requiring dental treatment because of the action or fault of another person, and if Delta Dental is unaware of other coverage, Delta Dental may pay benefits but would assume the subscriber’s or covered Eligible Dependent’s rights to recover from the other person.  The subscriber and covered Eligible Dependent would be required to help Delta Dental in making such a recovery.  This dental plan does not replace any workers’ compensation coverage.
5. If a subscriber or covered Eligible Dependent has two dental coverages, Delta Dental will coordinate benefits with the other coverage.  The following rules will be used to determine which coverage should be primary.



1. The program covering the patient as an employee is primary over a program covering the patient as a dependent.
2. Where the patient who is a Child who is an Eligible Dependent, primary dental coverage will be determined by the date of birth of the parents.  The coverage of the parent whose date of birth occurs earlier in the calendar year will be primary.  For a Child who is an Eligible Dependent of legally separated or divorced parents, the coverage of the parent with legal custody, or the coverage of the custodial parent's spouse (i.e.  stepparent) will be primary.
3. If there is a court decree stating that one parent has financial responsibility for a Child's dental care expenses, any dependent coverage of that parent will be primary to any other dependent coverage.


6. After a claim is processed, an Explanation of Benefits (“EOB”) will be sent to the subscriber.  If any payment for services was denied, the EOB will give the reason why.  If the subscriber disagrees with the denial, he or she must submit a request in writing asking that the claim be reviewed.  Such request should include the reason why the subscriber believes the claim was wrongly denied.  The request must be received by Delta Dental within 180 days of the subscriber’s receipt of the EOB.  Delta Dental will make a review and may ask for more documents if needed.  Unless unusual circumstances arise, a decision will be sent to the subscriber within 30 days after Delta Dental receives the request for review.

   If the subscriber does not agree with the first level review decision, he or she may refer the request for review to the Professional Relations Advisory Committee of Delta Dental.  This second level review request must be in writing and received by Delta Dental within a reasonable time after the subscriber receives the first level review decision.  Unless unusual circumstances arise, a decision will be sent to the subscriber within 30 days after Delta Dental receives the request for second level review.

   If the subscriber does not agree with the second level review decision, he or she may file civil action in court.

In addition to the limitations and exclusions shown in the Schedule of Benefits section, Delta Dental does not pay for the following:

1. Treatment of injury or illness covered by Workers' Compensation or Employer's Liability Laws.
2. Services received without cost from any federal, state or local agency.  This exclusion will not apply if prohibited by law.
3. Cosmetic surgery or procedures for purely cosmetic reasons.
4. Services for congenital (hereditary) or developmental malformations.  Such malformations include, but are not limited to, cleft palate or upper and lower jaw malformations.  This does not exclude those services provided under Orthodontic benefits, if covered.
5. Treatment to restore tooth structure lost from wear.
6. Treatment to rebuild or maintain chewing surfaces due to teeth out of alignment or occlusion or treatment to stabilize the teeth.  For example: equilibration, periodontal splinting and double abutments on bridges.
7. Oral hygiene and dietary instructions, treatment for desensitizing teeth, prescribed drugs or other medication, experimental procedures, conscious sedation and extra oral grafts (grafting of tissues from outside the mouth to oral tissues).
8. Charges by any hospital or other surgical or treatment facility and any additional fees charged by the dentist for treatment in any such facility.
9. Diagnosis or treatment for any disturbance of the temporomandibular joints (jaw joints) or myofacial pain dysfunction.
10. Services by a dentist beyond the scope of his or her license.
11. Dental services for which the patient incurs no charge.
12. Dental services where charges for such services exceed the charge that would have been made and actually collected if no coverage existed.
13. Delta Dental will apply the limitations and exclusions of this benefit plan based upon the member’s complete and prior history as reflected in Delta Dental’s records.

In the event a member transfers from one dentist to another during the course of treatment, payment by Delta Dental will be limited to the amount that would have been paid had only one dentist rendered the service.

Coverage for any subscriber or Eligible Dependent terminates when they are no longer eligible for benefits as a member of the group.

Specific state or federal laws or group polices may allow an extension of benefits for a limited time.  Delta Dental will determine whether any benefits are available and how long the benefits could be extended.