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DENTAL COVERAGE

DELTA DENTAL PLAN SUMMARY
The Delta Dental Plan gives you the freedom to choose your own dentist and receive coverage
from in-network and out-of-network providers. In addition, each member of your family can
use their own dentist.

There’s no better way to protect your smile than with regular dental checkups. TCW provides
employees with a wide network of dentists through Delta Dental’s preferred provider
organization (PPO) as well as through Delta Dental’s Premier Provider network. The plan
offers coverage for all basic dental services, as well as orthodontia.

Here is a brief summary of key features:

DELTA DENTAL PPO
NON-PARTICIPATING
PREMIER PROVIDER PROVIDER
PLAN SUMMARY PPO PROVIDER No balance billing over Patient may be billed for amount
negotiated rates
charged over negotiated rates
Calendar Year Deductible $50 / $150 $150 / $300 $150 / $300
Individual/Family
Calendar Year Maximum $1,500 $1,500 $1,500
Diagnostic & Preventive 100% 100% 100%
Basic Services 80% 70% 70%
Major Services 50% 40% 40%
Orthodontia (lifetime $1,000 $500 $500
maximum)
The above information is provided for illustrative purposes only. Refer to the applicable carrier material for exact description of plan
benefits and conditions.

YOUR DENTAL CONTRIBUTIONS

PLAN TYPE COVERAGE TIER EMPLOYEE SEMI-MONTHLY RATE
DENTAL
Employee $5.00
Delta Dental PPO Employee + 1 $15.00
Employee + Family $30.00

FINDING A PARTICIPATING DENTIST

There are thousands of general dentists and specialists to choose from nationwide —
so you are sure to find one who meets your needs. You can access a list of participating
dentists online at www.deltadentalins.com.

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