2018 Sunnyvale Benefit Summary

Dental

Under the Delta Dental Preferred Provider Organization (PPO) plan, dental services are provided

through the Delta Dental PPO network. However, you can visit dentists inside or outside the

network. What you pay depends on whether you choose a participating dentist. If you choose

a non-participating dentist, you pay the difference between the amount the dentist receives

from Delta Dental (the “allowable amount”) and the dentist’s charges.

You may also choose to visit a Delta Dental

Premier

provider. Premier dentists may not bill above

Delta Dental’s allowable amount, so your out-of-pocket costs may be lower than with a non-

participating dentist. Your costs are usually lowest when you visit a Delta Dental PPO dentist.

Pre-authorization from Delta Dental is recommended for charges of $250 or more.

SEA/Confidential, SEIU, SMA, PSMA, Unrepresented Management, Department Directors

Dental Benefits

Delta Dental PPO Core

Delta Dental PPO Buy up

In-Network

Out-of-Network*

In-Network

Out-Of-Network*

Calendar Year Deductible

$50 indiv / $150 family

None

$50 indiv /$150 family

Annual Plan Maximum

$1,100

$1,000

$1,600

$1,500

Diagnostic & Preventive

Plan pays 100%

Basic Services

Fillings

Plan pays 80%

Root Canals

Plan pays 80%

Periodontics

Plan pays 80%

Major Services

Plan pays 75%

Orthodontic Services

Orthodontia**

Plan pays 50%

Lifetime Maximum

$1,000

$1,500

Dependent Children

Covered to age 23

*Non-Delta Dentists are reimbursed at the lesser of the submitted charge or the fee that satisfies the majority of dentists in the same

geographical area with the same training (51st percentile of Usual, Customary and Reasonable)

**Orthodontic benefit can be prorated based on number of treatment months. Please see HR for more information.