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Dental - Yale University


									                                    Introducing Delta Dental
Effective 10/1/2010, Yale University will offer Graduate and Professional Students a voluntary dental insurance plan
through Delta Dental Insurance Company. The Delta Dental plan is designed to help maintain good oral health –
providing you and your family with the quality care you need at significant savings. Your coverage begins on the
effective date and there are no limitations for pre-existing conditions.

You may use any dentist under this plan, but you will maximize coverage and minimize out of pocket expense by using
a Delta Dental PPO dentist.

When you receive care from Delta Dental PPO network dentists, there is no co-payment for preventive and diagnostic
services like exams, cleanings, and X-rays. For other basic and major services obtained through Delta Dental PPO
dentists, although the plan does not pay a benefit, the dentist can charge no more than the Delta Dental PPO negotiated
fee for each service. An approved 2010 fee schedule for selected procedures is attached.

For services received through non-Delta Dental PPO dentists, the plan pays 80% of the maximum allowable charges for
preventive and diagnostic services like exams, cleanings, and X-rays. For these services, the dentist may collect from
you the difference between his or her billed fee and what the plan has allowed, as listed on the fee schedule on page 2.
There is no coverage for other basic and major services received from non-Delta Dental PPO dentists, and since Delta
Dental does not have a relationship with these dentists, you are responsible for the dentist’s billed fee.

Advantages in using Delta Dental PPO Dentists
No surprise costs – you know what your maximum out-of-pocket costs will be up front because all services received
from Delta Dental PPO network dentists – including fully covered preventive and diagnostic services and discounted
basic and major restorative services – are based on a fixed fee schedule.

No claim forms – when you go to a Delta Dental PPO network provider, there are no claim forms for you or your
family to complete. Simply provide your dentist with the information that is printed on your ID card, and make your
applicable patient payment.

No balance billing – Delta Dental PPO network dentists agree to accept the negotiated fee schedule amounts for
covered basic and major restorative services as full payment.

In-Network Coverage
In-network preventive diagnostic and services are covered 100% - which means that you won’t have any additional
out-of-pocket costs for those procedures identified as Type 1 on the list contained on page 2.

In-network basic and major restorative services – like fillings, crowns, and root canals are available to you at
discounted dental rates. We’ve negotiated discounts with our PPO providers so that you’ll have access to these services
at great savings for those procedures identified as Type 2 on the list contained on page 2.

Out-of-Network Coverage
When performed by out-of-network dentists, the plan only provides coverage for diagnostic and preventive services
identified as Type 1 on the list contained on page 2. For these services, members will be covered up to 80% of the lesser
of the maximum fee allowance or the dentist’s charge. For other basic services, prosthodontic, and other services,
identified as Type 2 and Type 3, respectively on page 2, there is no coverage and the plan does not offer any discount
for the service when it is provided by a non-participating dentist.
If you receive care from a non-participating dentist, you may be responsible for paying the dentist directly and
submitting a claim form to Delta Dental so that you can be reimbursed for the covered amount for diagnostic and
preventive services.

About the List of Covered Services
The fees listed below are in effect for 2010. Dentists’ fees are reviewed annually and may be adjusted in January. If the
fees are adjusted, your share of the patient payment may increase.

                                             CT Delta Dental PPOSM
                                 Fee Schedule - Effective 1/1/10 (Selected Procedures)

         CODE                                       DESCRIPTION                                          FEE
                   TYPE 1 – Diagnostic
         0120      Periodic Oral Evaluation                                                               $36
         0210      Intraoral-complete series (including bitewings)                                        $99
         0220      Intraoral periapical-single-first film                                                 $22
         0272      Bitewings-two films                                                                    $32
         0274      Bitewings-four films                                                                   $47
                   TYPE 1 – Preventive
         1110      Adult prophylaxis                                                                      $67
         1203      Topical application of fluoride (prophy not included)-child                            $28
         1351      Sealant-per tooth                                                                      $41
                   TYPE 2 – Restorative
         2140      Amalgam-one surface, primary or permanent                                             $102
         2150      Amalgam-two surface, primary or permanent                                             $130
         2330      Resin-based composite-one surface, anterior                                           $105
         2331      Resin-based composite-two surfaces, anterior                                          $136
         2332      Resin-based composite-three surfaces, anterior                                        $174
         2391      Resin-based composite-one surface posterior                                           $119
         2392      Resin-based composite-two surfaces, posterior                                         $157
         2393      Resin based composite-three surfaces, posterior                                       $200
         2750      Crown-porcelain-high noble metal                                                      $890
         3330      Root canal therapy-molar                                                              $890
                   TYPE 2 – Periodontics
         4260      Osseous surgery-4 or more teeth-per quad                                              $808
         4341      Perio scaling & root planing-4 or more teeth, per quad                                $190
         4910      Periodontal maintenance (following therapy)                                           $103
                   TYPE 3 – Prosthodontics - Removable
         5213      Maxillary partial denture-cast frame work-with resin denture base                     $1270
         5650      Add tooth to existing partial denture                                                 $146
                   TYPE 3 – Implant Services
         6065      Implant supported porcelain/ceramic crown                                             $1100
         6069      Abutment supported retainer for porcelain fused to metal PPD (high noble metal)       $1005
         6010      Endosteal Implant                                                                     $1716
                   TYPE 3 – Prosthodontics – Fixed
         6750      Crown-porcelain fused to high noble metal                                             $890
                   TYPE 3 – Oral Surgery
         7140      Extraction, erupted tooth or exposed root                                             $127
                   (elevation and/or forceps removal)
         7210      Surgical removal of erupted teeth                                                   $228
         7240      Removal of impacted tooth-completely bony                                           $385
                   TYPE 3 – Orthodontics
         8070      Comprehensive orthodontic treatment of the transitional dentition                   $4774

Delta Dental PPO Plan
Questions and Answers
    Q. What is the Delta Dental PPO Plan?

    A. Delta Dental PPO Plan is a plan in which members benefit from financial savings when receiving care from
       Delta Dental PPO network dentists. When using these dentists, preventive and diagnostic services are covered
       at 100%. Basic and major restorative services provided by network dentists are available to Delta Dental PPO
       Plan members at discounted rates.

        Students who elect coverage must remain on the plan for one year. If coverage is cancelled for any reason,
        students must wait to re-enroll during the next enrollment period for the following plan year.

    Q. How can I find out if the dentist I use or want to use is a Delta Dental PPO dentist?

    A. You can find a dentist in the Delta Dental PPO network, by visiting

    Q. My dentist is a Delta Dental dentist, but is not on the Delta Dental PPO list. Can I still use him/her?

    A. Delta Dental has several other dental programs and not all Delta Dental dentists participate in all Delta Dental
       programs. The Delta Dental PPO Plan provides out-of-network coverage for preventive and diagnostic
       services only; however, the benefits are lower than the coverage we offer when members use the services of a
       Delta Dental PPO dentist. For this reason, we recommend that you receive your dental care from a dentist that
       participates in the Delta Dental PPO network.

    Q. Are there any Delta Dental PPO dentists that I can select to receive specialty services?

    A. Yes. Delta Dental PPO dentists include a panel of specialists. Should you require specialty services, you may
       select a specialist from the Delta Dental PPO network.

     Q. If I have a pre-existing dental condition, may I be covered for that condition?

     A. There are no exclusions or limitations for pre-existing dental conditions.

If you have additional questions, please contact Delta Dental at 1-800-452-9310 or visit

To find a dentist in the Delta Dental PPO network, visit There are over 200 participating
dentists within a 5-mile radius of Yale University.

Open Enrollment is July 2nd – September 15th

       Coverage is for one year beginning October 1st through September 30th.
       Annual Premium is $140.04 for an individual, $247.92 for member & spouse or member and 1 child, and
        $570.12 for a family.

Payment in full is due at the time of enrollment via check made payable to Yale University.

This plan is non-refundable and ALL sales are final. Delta Dental ID cards will be mailed to the address that is on
the enrollment form.

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