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Martin County Sheriff's Office I Employee Benefit Highlights 12020-2021ti? <br /> i <br /> Delta Dental PPO Plan At-A-Glance <br /> Network Delta Dental PPO <br /> Calendar Year Deductible(CYD) In-Network Out-of-Network* <br /> • • <br /> Per Member $50 <br /> Per Family $150 _ - _ - <br /> Waived for Diagnostic&Preventative Services? Yes <br /> Locate a Provider <br /> Calendar Year Benefit Maximum <br /> • .. . To search for a participating provider, <br /> Per Member $1,500 contact Delta Dental's customer service <br /> or visit www.deltadentalins.com. <br /> Diagnostic&Preventive Care When completing the necessary <br /> search criteria,select Delta Dental PPO <br /> Routine Oral Exam(2 Per Year) network. <br /> Routine Cleanings(2 Per Year) <br /> Bitewing X-rays"" Plan Pays:100% Plan Pays:100% <br /> Deductible Waived <br /> [—CompleteX-rays(1 Every 5Years) - 7 Deductible Waived <br /> (Subject roBalance Billing) <br /> Sealants <br /> Deep Cleaning <br /> Plan References <br /> Basic Services *Out-Of-Network Balance Billing: <br /> Fillings(Amalgam and Composite) For information regarding out-of- <br /> [ <br /> -"��" network balance billing that may be <br /> • imple Extractions charged by an out-of-network provider, <br /> Endodontics(Root Canal Therapy) , plea se refer to the Out-of-Network <br /> — Plan Pays:100%After CYD Plan Pays:80%After CYD <br /> Oral Surgery (Subject to Balance Billing) Benefits section on the previous page. <br /> `Periodontics "Bitewing X-rays:One(1)set per <br /> ` calendar year for employee and spouse. <br /> General Anesthesia(Limitations Apply) Two(2)sets per calendar year for <br /> Major Services dependent children enrolled. <br /> — <br /> Crowns <br /> Dentures -I Plan Pays:60%After CYD Plan Pays:50%After CYD <br /> (Subject to Balance Billing) <br /> Bridges <br /> Orthodontia Important Notes <br /> Lifetime Maximum $1,500 •Each covered family member may <br /> Plan Pays:50% receive up to two(1) cleanin <br /> Benefit Plan Pays:50% Deductible Waived per calendar year coveredroutine under the Deductible Waived reventive benefit. <br /> (SubjecttoBalanceBilling) D <br /> •A pretreatment estimate is <br /> recommended for all work that is <br /> considered expensive.Member must <br /> ask their dentist to submit the request <br /> to Delta Dental. <br /> •Waiting periods and age limitations <br /> may apply. <br /> •Benefit frequency limitations may <br /> apply to certain services. <br /> 121 <br /> ©2016,Gehring Group,Inc.,All Rights Reserved 12 <br />