Dental Benefits

www.deltadentalsc.com

ELIGIBILITY

You must enroll online (see pages 6-7 in the Yellow Book for instructions) by November 17, 2023. Your effective date is on the first day of the month following two (2) full calendar months of employment. If you enroll dependents you must prove eligibility. Dependent Eligibility forms are found on the Enrollment site https://jmsmith.bcenroll.net under Posted Forms.

NOTE: If you do not enroll in Dental Benefits when first 'eligible', waiting periods for dental benefits apply.

DENTAL COVERAGE

Service	Coverage
Annual Deductible	$50 per person
Annual Maximum
Non-orthodontic care	$1,500 (per calendar year)
Orthodontic care	$1,500 (lifetime maximum)
PREVENTIVE SERVICES
Oral exams (2 exams per 12 months)	Plan pays 100% of the allowable charges, you pay 0% Waiting Period for Benefits to begin: None
Cleanings (2 exams per 12 months)	Waiting Period for Benefits to begin: None
Bitewing x-rays (2 every 12 months)
Full set of x-rays (every 36 months)
Space maintainers for dependent children under the age of 16.
Fluoride treatments for dependent children under the age of 18. (2 each calendar year)
Sealants for dependent children under the age of 18 once per tooth in any 36 months.
BASIC SERVICES
Fillings, other than gold.	Plan pays 80% of the allowable charges, you pay 20% (Subject to the deductible if not already met).
Extractions
Periodontics	Waiting Period for benefits to begin: Late Entrants Only - The first 6 months of the covered person's coverage.
Oral Surgery
Anesthesia
Laboratory tests
MAJOR SERVICES
Crowns,Dentures & Bridgework	Plan pays 50% of the allowable charges, you pay 50% (Subject to the deductible if not already met).
Repairs to crowns, bridges and dentures	Waiting Period for benefits to begin: Late Entrants Only - The first 6 months of the covered person's coverage.
Dental Implants
ORTHODONTIC SERVICES
Benefit is available for adults and children	Plan pays 50% of the allowable charges, you pay 50%
	Waiting Period for Benefits to begin: Late Entrants Only - The 1st 24 months of the covered person's coverage.

Note: This is a convenient brief summary. Always check your booklet certificate. The contract is the official source of information.

DENTAL BENEFITS GUIDE

Delta Dental Guide

CONTINUING COVERAGE AFTER I STOP WORKING

You may continue coverage for you and your covered dependents at your own expense under COBRA. You will be provided with information and costs upon leaving your employment with J M Smith Corporation.

Your dental benefits are administered by Delta Dental of Missouri (DDMO), a not-for-profit corporation.

You may visit the dentist of your choice and select any dentist on a treatment by treatment basis. It is important to remember your out-of-pocket costs may vary depending on your choice. You have three options:

PPO Participating Dentist (Delta Dental PPO Network). Delta Dental’s PPO network consists of dentists who have agreed to accept payment based on the lesser of usual fees or the applicable PPO Maximum Plan Allowance and to abide by Delta Dental policies. This network offers you cost control and claim filing benefits.
Non-PPO Participating Dentist (Delta Dental Premier Network). Delta Dental’s Premier network consists of dentists who have agreed to accept payment based on the lesser of filed fees or the applicable Premier Maximum Plan Allowance. This network also offers you cost control and claim filing benefits. However, your out-of-pocket expenses (deductibles and coinsurance amounts) may be higher with a Premier dentist, based upon your plan design.
Non-Participating Dentist If you go to a non-participating dentist (not contracted with a Delta Dental plan), DDMO will make payment directly to you based on the lesser of the dentist’s billed charge or the applicable Maximum Plan Allowance. It will be your obligation to make full payment to the dentist and file your own claim. A Dental Claim Form is available at the bottom of this page.