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- Bitewing X-rays are payable once per calendar year and full mouth X-rays (which include bitewing X-rays) are payable once in any five-year period. - Sealants are payable once per tooth per lifetime for the occlusal surface of first permanent molars up to age nine and second permanent molars up to age 14. The surface must be free from decay and restorations. - Composite resin (white) restorations are Covered Services on posterior teeth. - Porcelain and resin facings on crowns are optional treatment on posterior teeth. - Implants and implant related services are payable once per tooth in any five-year period. Having Delta Dental coverage makes it easy for you to get dental care almost everywhere in the world! You can now receive expert dental care when you are outside of the United States through ow Passport Dental program. This program gives you access to a worldwide network of dentists and dental clinics. English-speaking operators are available around the clock to answer questions and help you schedule care. For more information, check ow Web site or contact yow benefits representative to get a copy of our Passport Dental information sheet. Maximum Payment - $1,750 per person total per Benefit Year on all services except orthodontics. $1,000 per person total per lifetime on orthodontic services. Deductible - $25 Deductible per person total per Benefit Year limited to a maximum Deductible of $75 per family per Benefit Year. The Deductible does not apply to diagnostic and preventive services, emergency palliative treatment, brush biopsy, X-rays, sealants, and orthodontic services. Waiting Period -Employees who are eligible for dental benefits are covered on the date ofhire. Eligible People -All full-time employees of the Contractor working 40 bows per week who choose the dental plan and COBRA (Consolidated Omnibus Budget Reconciliation Act of 1985) enrollees, if applicable. The Contractor and Subscriber share the cost of this plan. Also eligible are yow legal spouse and your children under age 26, including yow children who are married, who no longer live with you, who are not your dependents for Federal income tax purposes, and/or who are not permanently disabled. You and yow eligible dependents must enroll for a minimum of 12 months. If coverage is terminated after 12 months, you may not re-enroll prior to the open enrollment that occurs at least 12 months from the date of termination. Yow dependents may only enroll if you are enrolled (except under COBRA) and must be enrolled in the same plan as you. Plan changes are only allowed during open enrollment periods, except that an election may be revoked or changed at any time if the change is the result of a qualifying event as defined under Internal Revenue Code Section 125. If you and your spouse are both eligible under this Contract, you maybe enrolled as both a Subscriber on yow own application and as a dependent on yow spouse's application. Yow dependent children may be enrolled on both applications as well. Delta Dental will coordinate benefits. Benefits will cease on the last day of the month in which the employee is terminated. Customer Service Toll-Free Number: (800) 524-0149 www.DeltaDentalOH.com April 1, 2015 KRN49615147