The Penn Faculty Practice Dental Plan for
Faculty & Staff of the University of Pennsylvania

This booklet describes the benefits available under the Penn Dental Plan. The Penn Dental Plan is one dental coverage option that is offered through the University of Pennsylvania Health and Welfare Program (the “Health and Welfare Program”). For more information regarding the Health and Welfare Program, including eligibility information and important legal information regarding the Program and your rights under federal law, employees are encouraged to visit the University's Human Resources web site at www.hr.upenn.edu, or call 1-888-PENNBEN (1-888-736-6236).

1. Eligibility
The Penn Dental Plan is open to all employees (and their eligible dependents) of the University of Pennsylvania who satisfy the eligibility requirements for participating in the Health and Welfare Program. For a more complete description of the Health and Welfare Program's eligibility rules, employees should refer to their enrollment materials or the summary plan description (SPD) for the Health and Welfare Program.

2. Enrollment in the Penn Dental Plan
Eligible employees of the University of Pennsylvania may enroll either upon or during the annual open enrollment period. Eligible new employees may enroll upon hire. With the exception of certain mid-year election changes described in Section 2.2, eligible dependents may be added to coverage only at the time that the employee enrolls or during an open enrollment period.

2.1 Effective Date of Coverage
For information regarding the effective date of coverage under the Health and Welfare Program, employees should refer to their enrollment materials or the SPD for the Health and Welfare Program.

2.2 Mid-Year Election Changes
Eligible employees are permitted to add or drop themselves and/or their dependents from coverage under the Penn Dental Plan on account of certain events (such as birth, adoption or marriage, etc.), provided notice is provided to the Benefits Office within 30 days of the event. You must report the event online via the University of Pennsylvania enrollment website at www.upenn.edu/u@penn (click on“Health benefits - view, enroll, change,” under Benefits) or call the Penn Benefits Center at 1-888-PENNBEN (1-888-736-6236). More information about change in status events can be found in the SPD for the Health and Welfare Plan.

3. Schedule of Benefits
The Penn Dental Plan provides the following coverage:

Type I Services – 100% Coverage

• Diagnostic, including routine examinations and consultations and radiographs (x- rays).
• Preventive, including fluoride applications for children under 19 years of age, prophylaxis (limited to not more than two times in a 12-month period), oral hygiene counseling, and nutritional counseling.
• Simple restorations including composites (tooth-colored fillings) for anterior teeth. Amalgams (silver fillings) for posterior teeth. The Penn Dental Plan benefit for a composite restoration on a bicuspid or molar is based on the alternative benefit of an amalgam restoration. The difference in charge is the patient's responsibility.
• Oral surgery (out of hospital only), including extractions**, incision and drainage of abscesses, alveolectomy and alveoloplasty, removal of oral cysts and tumors, and other routine oral surgical procedures performed in the office. The foregoing services shall be covered by the Penn Dental Plan only if such services are not covered by the patient's medical coverage.
• Emergency treatment, including palliative treatment for the relief of pain or discomfort.
• Repairs and adjustments, including recementation of inlays, crowns and bridges; and relining and repair of dentures not requiring laboratory work.

** In cases of extractions of third molar (wisdom teeth) full or partial bony impactions, the Penn Dental Plan will be billed secondary to the patient's primary health care plan. Coordination of benefit rules apply and shall not exceed 100% of the treatment cost.

Type II Services – 80% Coverage

• Periodontics, including subgingival curettage, root planing and scaling, periodontal maintenance and surgical periodontics.
• Endodontics, including pulp treatment, root canal therapy and apicoectomy.

Type III Services – 60% Coverage

• Major restorations, including inlays, crowns (when determined by the dentist to be necessary), and bridges.
• Dentures, including complete upper and/or lower dentures, partial dentures, and relining and repair of dentures requiring laboratory work.
• Space maintainers – prosthetic devices used in children to maintain the gap created by a missing tooth until the permanent tooth emerges.

Please refer to section 3.2 for limitations and exclusions.

Type IV Services – 60% Coverage

• Orthodontics, for children under age 19 (who have been enrolled in the plan for a minimum of 12 months); indications for orthodontics are an overbite of at least four millimeters, a crossbite, or protrusive or retrusive relationship of at least one cusp. Transfer of patients under treatment will be subject to a monthly treatment fee, which will be covered at the 60% level. Patients in treatment when their Penn Dental Plan coverage is no longer in effect will have their orthodontic benefit prorated by time remaining in treatment, a $2,000 lifetime maximum benefit.

Type V Services – 50% Coverage

• Surgically placed implants; $1,000 lifetime maximum, limited to a total of two implants per lifetime. Restorations on implants, including crowns and other prostheses, are covered at the usual level for that restoration. The implant abutment charge is excluded from coverage. Only crowns that are placed on covered implants will be a covered benefit of the plan. Please refer to section 3.2 for limitations and exclusions.

3.1 Emergencies
Emergency care is provided for patients of the Penn Dental Care Network on a 24-hour basis. If an emergency occurs outside of normal business hours, the subscriber should call (215) 898-4615 or any Network office for referral to the provider on call.

3.1.1 Out-of-the-Area Emergency Care
In the event that an emergency occurs when the subscriber is more than 50 miles away from a Penn Dental Care Network office, palliative treatments (treatment to alleviate the immediate discomfort) from a non-plan dentist is covered by the Plan. Examples of emergencies are pain, fever, swelling, bleeding, severe discomfort, or loss of a tooth.

Treatment from a non-plan dentist is limited to palliative treatment. Follow-up care must be provided by the Dental Care Network provider in order to be covered.

To receive reimbursement from the Penn Dental Plan, the subscriber must submit an itemized bill with a diagnosis and receipt of payment from the dentist who provided emergency treatment. If x-rays were taken, they should also be included.

The dentist's bill will be reimbursed to the subscriber at the Plan's regular benefit percentages for the service, based on the fees of the Penn Faculty Practice. The subscriber is responsible for any fees charged by the dentist who provided emergency treatment that are in excess of those covered by the Penn Faculty Practice Plan.

3.2 Limitations and Exclusions
The Penn Dental Plan has an annual maximum of $3,000 per plan year for each family member. The Penn Dental Plan will not cover work in progress on the date the coverage is scheduled to be effective. Work in progress is defined as any of the following:

• An appliance, or modification of one, where an impression was made before the patient was covered.
• A crown, bridge, or gold restoration for which the tooth was prepared before the patient was covered.
• Root canal therapy if the pulp chamber was opened before the patient was covered.

Other procedures not covered by the Plan include, but are not limited, to the following:

• Services or supplies not provided by the Penn Dental Care Network, except those required for emergency care outside of the area.
• Services provided under any government program or law under which the individual is, or could be, covered, as determined by the Penn Dental Plan.
• Restoration (bridge, crown, removable denture or implant) of a tooth or teeth missing or extracted prior to enrollment in the Penn Dental Plan. If the extraction was not performed at a Penn Dental Care Network office, the patient is responsible for obtaining documentation of the extraction's age.
• Replacement of an extracted primary tooth by an implant or fixed bridge.
• Replacement or upgrade of a previous restoration (bridge, crown, removable denture or implant) that is less than 60 months old. If the restoration was not performed at a Penn Dental Care Network office, the patient is responsible for obtaining documentation of the restoration's age.
• Upgrades (change in restoration or prosthetic device from what the patient had when entering the Penn Dental Plan) such as but not limited to a change from a removable appliance to fixed appliance, change from tooth supported to implant supported appliances. Unserviceable appliances that meet all the other criteria for replacement will be replaced by like appliances. The amount covered by the Penn Dental Plan may be used as partial payment towards an upgrade, it is the patient's responsibility to pay the difference.
• Abutments for dental implants.
• Prosthetic superstructure over implants (crowns, bridges, attachments, dentures) if the implant itself was not covered under the Penn Dental Plan.
• Occlusal appliances, including nightguards.
• Procedures necessary to alter the vertical dimensions or to restore occlusion for the purpose of splinting.
• Splinting teeth with permanent restorations (crowns) for periodontal purposes.
• Services necessitated by an accident related to employment or disease covered under the workers' compensation or similar law
• Replacement of lost or broken orthodontic appliances.
• Oral surgery and related expenses in a hospital.
• Any dentistry requiring hospitalization.
• General anesthesia - conscious (IV or Oral) sedation - for basic dentistry services (i.e. fillings, extractions). For complex extractions, the Penn Dental Plan Office will work with your primary health insurance company.
• Dentistry primarily for cosmetic purposes.
• A service provided while the patient's coverage is not in effect, except as provided under Section 5.1.
• TMJ treatment.

4. Cost of Coverage
Employees should refer to their enrollment materials for information on the amount of the employee contribution required for coverage under the Penn Dental Plan. Contributions are taken from pay before any federal income tax, FICA (Social Security) tax and Medicare Insurance tax are withheld. The state tax treatment will differ from state to state. There are exceptions to the pre-tax status of your contributions for a same-sex partner and a partner's child(ren) who are not your tax dependents. See the SPD for the Health and Welfare Plan for more information about these special situations.

5. Termination of Coverage
In general, coverage for the subscriber and family members will terminate if the subscriber ceases to be an eligible employee of the University of Pennsylvania or if the Penn Dental Plan is discontinued by the University of Pennsylvania. More detailed information about when and how coverage under the Penn Dental Plan may end is set forth in the SPD for the Health and Welfare Program.

5.1 Extension of Benefits
If coverage under the Penn Dental Plan is terminated for you or a family member, the protection will be extended to cover work in progress or Type I services received within the next 30 days provided that these services would have been covered had the Plan remained in effect. Payment for treatment received after this extension period will be on a fee-for-service basis.

6. Subscriber Responsibilities
Subscribers under the Penn Dental Plan are expected to

• Seek all dental care from Penn Dental Care Network offices.
• Subscribers are expected to pay their portion, if any, at the time of their visit. In the case of multiple visit procedures, the patient can make financial arrangements with the office manager for the course of treatment as long as the balance is paid in full prior to completion. No financial arrangements can be made to extend payment after treatment is completed (this includes orthodontic treatment).
• Notify the Benefits Office of any changes in family status affecting covered dependents.
• Give at least 24-hours notice for cancellation of appointments. If a subscriber or his or her dependents fail to give advance notice (minimum 24 hours) a letter will be sent notifying subscriber that future failed or broken appointments (less than 24 hours) will require a charge. Subscribers are expected to pay the broken or failed appointment fees before scheduling future appointments for dental treatment. Subscribers who fail and/or break more than three appointments during a plan year may be eliminated from the Penn Dental Plan at the end of that plan year.
• Be on time for all appointments.
• Maintain good dental health habits.
• Notify their provider at the next appointment of any changes in medical history.
• Be present when a minor child is having dental treatment.

7. Coordination with Other Plans
The Penn Dental Plan coordinates the benefits it pays on behalf of an individual with payments that may be made under other plans covering the individual so that the total benefits available will not exceed 100% of the allowable expenses.

An allowable expense is any necessary, reasonable, and customary expense covered, at least in part, by one of the “plans.” For this purpose, the term “plans” refers to the following types of medical and dental care benefit programs: (a) a government program or coverage required by statute, including no-fault coverage to the extent required in policies or contracts by a motor vehicle insurance statute or similar legislation; and (b) group insurance through employment or other coverage obtained through an educational institution above the high school level.

When a claim is made, the primary plan pays its benefits without regard to any other plans. The secondary plans adjust their benefits so that the total benefits available will not exceed the allowable expenses. The Penn Dental Plan will not pay more than it would have paid if there was no other plan. A plan without a coordination provision is always the primary plan. If all plans have a coordination provision, the plan covering the patient directly, rather than as a dependent, is the primary plan. If both parents cover a dependent child, except for situations where the parents are separated or divorced, the plan of the parent whose date of birth (month, day) falls earlier in the calendar year is the primary plan for that child. If both parents have the same birth date, the plan that covered the parent longer shall be primary.

8. Statement of Rights of the University
As with any other coverage option provided under the Health and Welfare Program, the University (acting through its Vice President for Human Resources) reserves the right to amend or terminate the Penn Dental Plan, in whole or in part, at any time.

9. Resolution of Questions Regarding Services
If a subscriber believes that he or she has not been provided with sufficient information about the Penn Dental Plan or has been denied a benefit under the Penn Dental Plan, the subscriber may file a written claim to:

Elaine Koch
Practice Administrator
Penn Dental Center at University City
3401 Market St.
Philadelphia, PA 19104

Any concerns regarding billing, should be directed to:

Debbie Ditomo
Penn Dental Care Network Billing Coordinator
University of Pennsylvania
Patient Billing
711 Lancaster Ave.
Bryn Mawr, PA 19010
610-520-4544

Detailed information about filing claims and appealing denied claims for benefits under the Penn Dental Plan is set forth in the SPD for the Health and Welfare Program.