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Pathfinder Pequot Lakes <br /> Presented By:IEB A DELTA DENTAL" <br /> o F Nr T A l_ MN,56472 <br /> Pathfinder Value Proposal Underwritten&Administered by Delta Dental of Minnesota <br /> $1,000 Calendar year Annual Coverage Maximum/per person <br /> Benefits are based on provider at time of service <br /> Delta Dental Network Options <br /> Service Benefit Summary www.deltadental.com <br /> Delta PPO Delta Premier Non-Delta <br /> Provider <br /> Preventive Services Preventive&Diagnostic Services: <br /> $100 Lifetime Deductible applies Oral evaluations/check-ups,X-rays, 100% 100% 100% <br /> No waiting period dental cleanings,fluoride treatments <br /> Basic Restorative Care&Services: <br /> composite(white)fillings,sealants, <br /> space maintainers,palliative treatment <br /> for emergencies <br /> Basic Services Endodontic Services: <br /> $100 Lifetime Deductible applies pulpal therapy,root canal therapy, 80% 80% 80% <br /> No waiting period pulpotomy <br /> Periodontal Services: <br /> non-surgical and surgical <br /> periodontal care <br /> Oral Surgery Services: <br /> Basic Services basic extraction of erupted tooth <br /> $100 Lifetime Deductible applies or exposed root,surgical removal of 55% 50% 50% <br /> 6-month waiting period erupted tooth,impacted teeth and <br /> tooth roots <br /> Restorative Care Services: optional optional optional <br /> inlays treatment treatment treatment <br /> y (***) (***) (***) <br /> Major Services onlays,crowns and crown repairs(*) 55% 50% 50% <br /> $100 Lifetime Deductible applies Prosthetic Services: <br /> 12-month waiting period removable prosthetic <br /> services-dentures and partials(*)(**), 55% 50% 50% <br /> fixed prosthetic services-bridges(*)(**), <br /> repairs-removable and fixed <br /> Implants <br /> *Coverage does not include the following crown or bridge services:buildups,pins,posts and cores. <br /> **Missing-tooth exclusion applies during the first 24 months of coverage. <br /> ***Member receives the amalgam benefit for the least costly commonly performed course of treatment. <br /> Waiting period takeover-If the group has at least 12 months of prior comparable coverage,and no gap between that coverage and the Pathfinder <br /> effective date,ALL members of the group will receive a waiver of the Pathfinder waiting periods,with the following exceptions:The waiver does not <br /> apply to employees/dependents who join the group or enroll for Pathfinder coverage after the initial Pathfinder effective date. <br />