Where to go for more information
1(800) 464-4000 http://www.kaiserpermanente.org
Trust Fund Office 1(888)547-2054 or 1(510) 633- 0333 www.carpenterfunds.com
dENTal BENEFITs - FoR KaIsER & INdEmNITy PaRTICIPaNTs
In-Network: Delta Dental PPO Dentist
Maximum - $2,500 per patient per calendar year Diagnostic & Preventive - 100% Contract Rate Basic Services - 80% Contract Rate Crowns & Cast Restorations - 80% Contract Rate Prosthodontics - 80% Contract Rate
Outside of Delta Dental PPO Network
Maximum - $2,000 per patient per calendar year Diagnostic & Preventive - 100% Contract Rate Basic Services - 50% Contract Rate Crowns & Cast Restorations - 50% Contract Rate Prosthodontics - 50% Contract Rate
The maximum benefit is $2,500 per year, reduced to $2,000 for services of Non-PPO dentists. The above maximums are not separate maximums.
Orthodontic Benefits for Dependent Chil- dren
Benefits covered by Indemnity Medical Plan, not Delta Dental. Plan pays 50% of cov- ered charges to a maximum of $1,500 per dependent child to the age of 19.
A drug identified by its chemical name - an equivalent version of a brand name drug whose exclusive patent has expired.
A brand name drug that has a generic equivalent.
Single Source Formulary Brand
A brand name drug that has no generic equivalent and is placed on a list of preferred formulary drugs by the pharmacy benefit manager.
A drug that is NOT on a list of preferred formulary drugs.
The dollar amount the Fund has determined it will allow for covered Medically Neces- sary services or supplies performed by Non-Contract Providers.
Phantom COB (Coordination of Benefits)
If the participant’s spouse is employed and the employer offers insurance, the spouse must elect coverage.
Plan A & R Comparison