2020 Dental Benefits Guide

Delta Dental PPOTM NetworkThe Delta Dental PPO network has over 278,000 Participating Dentist locations nationwide. Your savings are the greatest when you utilize this network. You MUST utilize a Delta Dental PPO dentist when enrolling in the Basic Dental Plan or NO SERVICES WILL BE COVERED. Delta Dental Premier® NetworkIf you are enrolled in the Basic Plan and you visit a Delta Dental Premier dentist, no services will be covered.

If you are enrolled in the Premium Plan and a Delta Dental PPO dentist cannot be utilized, it’s then best to seek services from a Delta Dental Premier dentist. There are over 342,000 Participating Dentist locations nationwide. Why Stay in Network?In addition to greater savings, both Delta Dental PPO and Delta Dental Premier dentists will file all claims directly with Delta Dental and cannot “balance bill” you when their charges exceed the maximum plan allowance. With our extensive provider networks, it’s easy to find an in-network dentist near you. Out-of-NetworkIf you are enrolled in the Basic Plan and you visit an out-of-network dentist, no services will be covered.

If you are enrolled in the Premium plan and choose to use an out-of-network dentist, you may be responsible for paying the dentist and filing your own claims. Claims can be mailed to Delta Dental of Kansas at: PO Box 789769, Wichita, KS 67278. You can download a claim form at DeltaDentalKS.com/Sprint. Any reimbursement for those claims will be paid directly to you.

Online Member Account

Find a DentistYour Dentist Network Options

Log in to your online member account at DeltaDentalKS.com/Sprint to:

• Check claims information• View benefits and eligibility• Print or save your benefit information• Print an ID card• Live Chat with a Customer Service

Representative• Access member-only discounts• And more!

If this is your first time visiting your member account, you will need to register for an account using the member ID provided on your Delta Dental ID card.

Using Your Dental Plan

Maximize your benefits by visiting a Delta Dental PPO dentist. Easily find a dentist at DeltaDentalKS.com/Sprint, on Delta Dental’s mobile app or by contacting customer service at 866.913.3375.

At DeltaDentalKS.com/Sprint, or on Delta Dental’s mobile app, use the ‘Find a Dentist’ tool and select Delta Dental PPO for the Basic Plan and either Delta Dental PPO or Delta Dental Premier for the Premium Plan. You can search for dentists and specialists in your area that have the qualities that matter to you. Find a dentist close to work or home, and filter by gender, language spoken or accessibility features.

Download the Delta Dental mobile app today by visiting the Apple App Store or Google Play and search for Delta Dental.

Customer Service: 866.913.3375 | DeltaDentalKS.com/Sprint

Delta Dental1619 N. Waterfront ParkwayP.O. Box 789769Wichita, KS 67278-9769

Delta Dental of Kansas complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.

ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-800-234-3375 (TTY: 1-800-234-3375).

CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-800-234-3375 (TTY: 1-800-234-3375).

Dental Benefits Summary January 1 – December 31, 2020

What will I pay?

Your dental plan helps you pay for dental services & procedures. Similar to medical insurance, deductibles, coinsurance and annual individual benefit maximums are all ways the cost is shared between you and your plan, making care more affordable:

Deductible - The amount you must pay out-of-pocket before your plan begins to pay.

With your dental plan, Diagnostic & Preventive care will not require a deductible.

Coinsurance - The fixed percentage you pay as your share of the cost of a covered service. Coinsurance kicks in after you meet any required deductible.

The coinsurance percentages shown to the left are the amount that your plan pays towards a covered service. Your responsibility is the remaining coinsurance percentage.

Annual Individual Benefit Maximum - The most money your plan will pay for claims during the course of your benefit period (Jan. 1 - Dec. 31, 2020). Your dental plan pays the coinsurance amounts shown to the left. If/when your dental plan coinsurance payments add up to the annual maximum, your claims for services after that are 100% your responsibility for the remainder of the benefit period.

What else should I know?

Predeterminations - What are they and why are they helpful? A predetermination of benefits allows you to know in advance what procedures are covered by your dental plan, the amount your plan will pay towards a treatment and your financial responsibility. Predeterminations are submitted by your dentist before treatment. It is recommended that your dentist submit a predetermination whenever dental work is being considered that is beyond Diagnostic and Preventive care. This allows you to plan for the cost of the services that will be your responsibility to pay.

Maximum Plan Allowance - When dentists agree to become part of Delta Dental’s PPO or Premier network, they agree to accept established fees for service, or the Maximum Plan Allowance. These fees are less than what the dentist would normally charge, so you know you’ll be saving money before you even sit down in the dentist’s chair. In-network dentists have also agreed not to “balance bill” you for the difference between the agreed upon fee (maximum plan allowance) and their usual fee, which commonly occurs if you visit an out-of-network dentist. Dental benefits (coinsurance) are based on Delta Dental’s Maximum Plan Allowances.

Basic Plan Premium Plan

Delta DentalPPOTM Network

Dentists

Delta DentalPremier® Network

Dentists

Out-of-NetworkDentists

Delta Dental PPOTM

Network Dentists ONLY

(Coverage NOT provided for Premier Dentists or

Out-of-Network Dentists)

Your Network Options

Choose between the Basic Plan or Premium Plan

Service Type

Diagnostic & Preventive Care

(Routine exams, cleanings, X-rays, sealants and

fluoride treatments, etc.)

General Dental Care(Fillings, extractions, non-surgical

periodontal services and other basic dental procedures)

Annual Individual Benefit Maximum

(Diagnostic & Preventive Care does NOT apply towards the

Annual Maximum)

Orthodontia(Braces, limited TMJ coverage)

Orthodontia Lifetime Benefit Maximum

100%

2 visits per year(no deductible)

100%

2 visits per year(no deductible)

70%2 visits per year(no deductible)

70%2 visits per year(no deductible)

80%*($50 annual deductible)

50%* ($50 annual deductible)

50%*($50 annual deductible)

50%

($25 annual deductible)

Major & Restorative Care(Crowns, root canals, surgical

periodontal services, bridges, dentures, etc.)

***Newly enrolled participants may only be covered for certain major & restorative

services after a waiting period***

50%($25 annual deductible)

$750 $1,500

(does not include orthodontia)

NOT COVERED 50%

($50 lifetime orthodontia deductible, separate from annual deductible)

$1,500(separate from non-orthodontia maximum)

NOT COVERED

*IMPORTANT: If a member enrolled in the Sprint Premium Plan for more than 12 months has not had a routine cleaning or exam in the preceding 12 months, all listed General Dental Care services are reduced to fifty (50%) percent coverage by a PPO dentist, or forty (40%) percent for Premier and Out-of-Network dentists. Once the qualifying cleaning or exam has been received, benefits will return to the original coinsurance the first day of the following month. Newly enrolled members will have 12 months to satisfy this requirement.**IMPORTANT: If a member enrolled in the Sprint Premium Plan for more than 12 months has not had a routine cleaning or exam in the preceding 12 months, all listed Major & Restorative Care services are reduced to forty (40%) percent coverage for services by a PPO dentist, or thirty (30%) percent for Premier and Out-of-Network dentists. Once the qualifying cleaning or exam has been received, benefits will return to the original coinsurance the first day of the following month. Newly enrolled members will have 12 months to satisfy this requirement.

NOTE: This represents a summary of coverage. Details in the Summary Plan Description govern in all cases.

Dental implants at 50% of maximum plan allowance subject to a separate $50

annual deductible

50%**($50 annual deductible)

40%**($50 annual deductible)

Dental implants at 40% of maximum plan allowance subject to a separate $50

annual deductible

40%**($50 annual deductible)

Dental implants at 40% of maximum plan allowance subject to a separate $50

annual deductible

Amount of Maximum Plan Allowance Covered by Your Dental Plan (Coinsurance):