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Plan Guidelines MESSA Dental Plans MESSA dental plans are underwrien and administered by Delta Dental of Michigan, a non-profit dental care corporaon known for its high quality dental programs. Delta Dental contracts with densts throughout the U.S. to provide high quality care and 90% of Michigan densts are in the Delta Dental provider network. MESSA members can easily locate Delta Dental contracng providers by vising www.messa.org and using the provider directory search provided by Delta Dental. The following chart describes the four classes of dental benefits and provides guidelines to assist in designing a group’s dental benefit program: MES - FS Rev. 8/11/14 Pr. 1 PDF • Necessary treatment and procedures required for the correcon of abnormal bite. • Orthodonc exam, radiographs and extracons are covered under Diagnosc & Prevenve Services and Basic Services. Rider Adult orthodoncs: removes the age 19 restricon on Orthodoncs coverage. For a complete lisng of exclusions and limitaons that apply to the plan, refer to the Delta Dental of Michigan cerficate booklet. Must have both Diagnosc & Prevenve Services and Basic Services benefits Major Services percentage cannot exceed Diagnosc & Prevenve Services and Basic Services Orthodoncs percentage cannot exceed Diagnosc & Prevenve Services and Basic Services. Must have Diagnosc & Prevenve Services, Basic Services, and Major Services benefits Diagnosc & Prevenve Services 50 percent up to 100 percent in increments of 5 percent ______ percent Basic Services 50 percent up to 100 percent in increments of 5 percent ______ percent Major Services 50 percent up to 100 percent in increments of 5 percent ______ percent Orthodoncs 50 percent up to 100 percent in increments of 5 percent ______ percent • Oral examinaon • Prophylaxes • Topical fluoride • Brush biopsy • Emergency palliave • Two cleanings in 12 months Rider Three or four cleanings every 12 months. • Radiographs (X-rays)* • Restorave • Crowns** • Oral surgery • Endodonc services — treatment for diseased or damaged nerves. • Periodonc services — treatment for diseases of the gum and teeth-supporng structures. * Bitewing X-rays are payable once in any period of 12 consecuve months. Full mouth panograph is payable once in five years. ** Payable once in any five-year period on the same tooth. Rider Sealants: payable on occlusal surface of first permanent molars for paents up to age 9 and for second permanent molars for paents up to age 14 that are free from caries and restoraons. • Procedures for the construcon of fixed bridgework, endosteal implants, paral and complete dentures. • Payable once in any five-year period for the same appliances. Diagnosc & Prevenve Services, Basic Services, and Major Services have a combined annual maximum, which can be $1,000 or more in increments of $100 up to the amount bargained. Orthodoncs has a lifeme maximum per person, which can be $500 or more in increments of $100 up to the amount bargained. Examples: Copayment Diagnosc & Prevenve Services, Basic Services, and Major Services 100/90S/90 (includes sealant) OR 80/80/80 Maximum Diagnosc & Prevenve Services, Basic Services, and Major Services $1,500 $1,500 Copayment Orthodoncs 90 80 Ortho Maximum $4,000A (includes adult ortho) $3,000

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Plan Guidelines

MESSA Dental Plans

MESSA dental plans are underwritten and administered by Delta Dental of Michigan, a non-profit dental care corporation known for its high quality dental programs. Delta Dental contracts with dentists throughout the U.S. to provide high quality care and 90% of Michigan dentists are in the Delta Dental provider network. MESSA members can easily locate Delta Dental contracting providers by visiting www.messa.org and using the provider directory search provided by Delta Dental. The following chart describes the four classes of dental benefits and provides guidelines to assist in designing a group’s dental benefit program:

MES - FSRev. 8/11/14Pr. 1 PDF

• Necessary treatment and procedures required for the correctionofabnormalbite.

•Orthodonticexam,radiographs andextractionsarecovered underDiagnostic&PreventiveServicesandBasicServices.

RiderAdultorthodontics:removestheage19restrictiononOrthodonticscoverage.

Foracompletelistingofexclusionsandlimitationsthatapplytotheplan,refertotheDeltaDentalofMichigancertificatebooklet.

Must have both Diagnostic & Preventive Services and Basic Services benefits

Major Services percentage cannot exceed Diagnostic & Preventive Services and Basic Services

Orthodontics percentage cannot exceed Diagnostic & Preventive Services and Basic Services. Must have Diagnostic & Preventive Services, Basic Services, and Major Services benefits

Diagnostic & Preventive Services50 percent up to 100 percentin increments of 5 percent______ percent

Basic Services 50 percent up to 100 percentin increments of 5 percent______ percent

Major Services 50 percent up to 100 percentin increments of 5 percent______ percent

Orthodontics50 percent up to 100 percentin increments of 5 percent______ percent

•Oralexamination•Prophylaxes•Topicalfluoride•Brushbiopsy•Emergencypalliative•Twocleaningsin12monthsRiderThreeorfourcleaningsevery12months.

•Radiographs(X-rays)*•Restorative•Crowns**•Oralsurgery•Endodonticservices— treatment for diseased or damagednerves.• Periodonticservices— treatment for diseases of thegumandteeth-supporting structures.*BitewingX-raysarepayableonceinanyperiodof12consecutivemonths.Fullmouthpanographispayableonceinfiveyears.

**Payableonceinanyfive-yearperiodonthesametooth.

RiderSealants:payableonocclusalsurfaceoffirstpermanentmolarsforpatientsuptoage9andforsecondpermanentmolarsforpatientsuptoage14thatarefreefromcariesandrestorations.

•Proceduresfortheconstructionoffixedbridgework,endostealimplants,partialandcompletedentures.

•Payableonceinanyfive-year period for the same appliances.

Diagnostic & Preventive Services, Basic Services, and Major Serviceshaveacombinedannualmaximum,whichcanbe$1,000ormoreinincrementsof$100uptotheamountbargained.

Orthodontics hasalifetimemaximumperperson,whichcanbe$500ormoreinincrementsof$100uptotheamountbargained.

Examples: CopaymentDiagnostic & Preventive Services, Basic Services, and Major Services

100/90S/90(includessealant)OR80/80/80

MaximumDiagnostic & Preventive Services, Basic Services, and Major Services

$1,500

CopaymentOrthodontics

OrthoMaximum

$4,000A(includesadultortho)

$3,000

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