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C&T, S&M, Security and YPBA Dental Plans

Delta Dental Assistance Plan

Below is a general summary of covered services under the Dental Assistance Plan administered by Delta Dental. There is no annual deductible and no out-of-pocket maximum. This is a brief summary and the plan documents will prevail. For more information see the Delta Dental Summary of Benefits for staff members.

Click here for instructions on how to obtain an ID card.

Service Category	Covered Services	Percentage Reimbursement
Preventive & Diagnostic	Oral exam Fluoride treatment Prophylaxis/Cleaning Sealants X-rays Space maintainers Emergency treatment to relieve dental pain when no other definitive dental services are performed	100% (up to the maximum allowable amount)
Basic Restorative	Amalgam restorations Composite restorations Oral surgery/extractions Endodontics (root canal therapy) Local anesthetic, analgesic and routine post-operative care of extractions and other surgery General anesthetic when medically necessary in conjunction with oral or dental surgery, and if the anesthetic agent produces unconsciousness	80% (up to the maximum allowable amount)
Major Restorative	Crowns Inlays, onlays	50% (up to the maximum allowable amount)

CIGNA DMO Dental Care Plan (closed to new enrollment)

Under the CIGNA DMO Dental Care Plan, there are no forms, deductibles or annual or lifetime maximums. You are responsible for paying a patient charge directly to the provider when you or a dependent receives care and you must see a CIGNA DMO provider in order to have benefits paid. Click here for the CIGNA DMO Providers Directory.

Covered Services:

• Preventative care: no patient charges apply to most preventative procedures
• Restorative care: several restorative and specialty procedures are available for low, pre-set fees
• Oral surgery
• Periodontics
• Orthodontic care
• View CIGNA's 2013 Schedule of Fees