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Last modified
3/27/2018 10:28:51 AM
Creation date
3/27/2018 10:16:23 AM
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Contracts
Company Name
DELTA DENTAL
Contract #
A-2018-021
Agency
PERSONNEL SERVICES
Council Approval Date
2/6/2018
Expiration Date
12/31/2019
Destruction Year
2024
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(m) Occlusal guards and complete occlusal adjustment. <br />(n) Orthodontic services (treatment of mal -alignment of teeth and/or jaws). <br />(o) Diagnostic casts. <br />4.8 An agreement between the Contractholder and Delta Dental Is required to change Benefits <br />during a Contract Term, <br />ARTICLE; 5 - DEDUCTIBLES & MAXIMUM AMOUNT <br />5.1 Applicable to services provided by a Delta Dental PPO Dentist: Each Enrollee must pay <br />the first $25 ("deductible amount") of fees for services that are Benefits received by an <br />Enrollee during the term of this Contract and otherwise covered by this Contract, such <br />deductible amount will not exceed $50 for all Enrollees in a single family, consisting of a <br />Primary Enrollee and his or her Dependents, as defined, Delta Dental will compute these fees <br />based on the Dentist's Usual, Customary and Reasonable fees, <br />Applicable to services provided by other dentists: Each Enrollee must pay the first $50 <br />("deductible amount") of fees for services that are Benefits received by an Enrollee during the <br />term of this Contract and otherwise covered by this Contract. Such deductible amount will not <br />exceed $100 for all Enrollees in a single Family, consisting of a Primary Enrollee and his or her <br />Dependents, as defined, Delta Dental will compute these fees based on the Dentist's Usual, <br />Customary and Reasonable fees. <br />5.2 Such deductible amounts shall apply once each calendar year or portion thereof during which <br />the Enrollee Is continuously eligible under this Contract. The deductible does not apply to <br />Diagnostic and,Preventive Benefits. <br />5.3 Applicable to services provided by a Delta Dental PPO Dentist: The maximum amount <br />Delta Dental will pay for Diagnostic and Preventive, Basic, Crowns, Inlays, Onlays and Cast <br />Restorations and Prosthodontic Benefits provided to any Enrollee In a calendar year is 1,250. <br />Applicable to services provided by other dentists: The maximum amount Delta Dental <br />will pay for Diagnostic and Preventive, Basic, Crowns, Inlays, Onlays and Cast Restorations <br />and Prosthodontic Benefits provided to any Enrollee In a calendar year is 1,000, <br />ARTICLE 6 - COORDINATION OF BENEFITS <br />6.1 If'a group insurance policy or any other group health Benefits plan, Including another Delta <br />Dental plan, entitles a person to receive or be reimbursed for the cost of dental services, <br />which are also Benefits under this plan, and If this plan Is "primary" under the rules described <br />below, Delta Dental will provide Benefits as If the other plan did not exist. If the other plan Is <br />"primary" under these rules, then Delta Dental will coordinate Benefits under this plan with <br />the primary plan in accordance with California law (California Health and Safety Code <br />1374.19 (2007). <br />6.2 If the other plan mainly covers services or expenses other than dental care, this plan is <br />"primary." Otherwise, Delta Dental will use the following rules to determine which plan is <br />"primary": <br />(a) The plan that covers the person as other than a Dependent Is primary over the plan <br />that covers the person as a Dependent, with the following exception: <br />If the person is also a Medicare Beneficiary and Medicare is: <br />(1) secondary to the plan covering the person as a Dependent; and <br />to <br />26C-62 <br />
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