CAEOC(2005) V5 DeltaCare USA A Prepaid Dental Plan for UNIVERSITY OF CALIFORNIA Employees, Retirees, and Their Dependents Evidence of Coverage and Disclosure Statement January 1, 2006 Provided by: 12898 Towne Center Drive Cerritos, CA 90703-8579 (800) 422-4234 www.deltadentalins.com/deltacareusa
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CAEOC(2005) V5
DeltaCare USA
A Prepaid Dental Plan for
UNIVERSITY OF CALIFORNIAEmployees, Retirees, and Their Dependents
Evidence of Coverage and Disclosure Statement
January 1, 2006
Provided by:
12898 Towne Center DriveCerritos, CA 90703-8579(800) 422-4234www.deltadentalins.com/deltacareusa
EVIDENCE OF COVERAGEDISCLOSURE FORM
OF THE PMI GROUP DENTAL PLAN FOR ELIGIBLE EMPLOYEES AND RETIREES OF
THE UNIVERSITY OF CALIFORNIA
DeltaCare USA Dental Health Care Program
This Evidence of Coverage of the PMI Group Dental Plan has been prepared for participants who are Employees and Retirees of the University of California.
This booklet describes the plan beneÞ ts in everyday terms whenever possible. Not all details are included in every case.
This Plan has been established and is maintained and administered in accordance with the provisions of Group Dental Contract Number AG109.UC issued by:
PMI Dental Health Plan12898 Towne Center DriveCerritos, CA 90703-8579
(800) 422-4234(562) 924-8311
IMPORTANT
This booklet is subject to the provisions of the Group Dental Service Contract and The University of California Group Insurance Regulations and cannot modify or affect the provisions of these documents in any way, nor shall you accrue any rights because of any statement in or omission from this booklet. Some provisions of this Plan may not apply to Employees in certain exclusively represented bargaining units.
CAEOC(2005) V5
This booklet is a Combined Evidence of Coverage and Disclosure Form (�EOC�) for your DeltaCare USA Dental Health Care Program (�Program�) provided by Private Medical-Care, Inc. (�PMI�). The Program has been established and is administered in accordance with the provisions of a Group Dental Service Contract (�Contract�) issued by PMI.
THE EOC CONSTITUTES ONLY A SUMMARY OF THE PROGRAM. AS REQUIRED BY THE CALIFORNIA HEALTH & SAFETY CODE, THIS IS TO ADVISE YOU THAT THE CONTRACT MUST BE CONSULTED TO DETERMINE THE EXACT TERMS AND CONDITIONS OF THE COVERAGE PROVIDED UNDER IT.
A COPY OF THE CONTRACT WILL BE FURNISHED UPON REQUEST. ANY DIRECT CONFLICT BETWEEN THE CONTRACT AND THE EOC WILL BE RESOLVED ACCORDING TO THE TERMS WHICH ARE MOST FAVORABLE TO YOU. PLEASE READ THIS EOC CAREFULLY AND COMPLETELY. PERSONS WITH SPECIAL HEALTHCARE NEEDS SHOULD READ THE SECTION ENTITLED �SPECIAL NEEDS�.
A STATEMENT DESCRIBING PMI�S POLICIES AND PROCEDURES FOR PRESERVING THE CONFIDENTIALITY OF MEDICAL RECORDS IS AVAILABLE AND WILL BE FURNISHED TO YOU UPON REQUEST.
PLEASE READ THE FOLLOWING INFORMATION SO YOU WILL KNOW FROM WHOM OR WHAT GROUP OF PROVIDERS DENTAL CARE MAY BE OBTAINED.
The telephone number at which you may obtain information about beneÞ ts is (800) 422-4234.
Schedule B Enrollees should discuss alltreatment options with their Contract Dentist prior to services being rendered.
Text that appears in italics below is specifically intended to clarify the deliveryof benefits under the DeltaCare USA program and is not to be interpreted asCDT-2005 procedure codes, descriptors or nomenclature that are undercopyright by the American Dental Association. The American DentalAssociation may periodically change CDT codes or definitions. Such updatedcodes, descriptors and nomenclature may be used to describe these coveredprocedures in compliance with federal legislation.
CODE DESCRIPTION PAYS
radiographslimited to 1 series every 12 months
radiographradiographsradiographs limited to 1 series every 6