Delta Dental PPO (Point-of-Service) Summary of Dental Plan Benefits For Group# 10137-0003, 3099 University of Cincinnati Comprehensive Dental Plan
This Summary of Dental Plan Benefits should be read along with your Certificate. Your Certificate provides additional information about your Delta Dental plan, including information about plan exclusions and limitations. If a statement in this Summary conflicts with a statement in the Certificate, the statement in this Summary applies to you and you should ignore the conflicting statement in the Certificate. The percentages below are applied to Delta Dental's allowance for each service and it may vary due to the dentist's network participation.* Control Plan – Delta Dental of Ohio Benefit Year – January 1 through December 31 Covered Services – Delta Dental PPO Dentist Delta Dental Premier Dentist Nonparticipating Dentist Plan Pays Plan Pays Plan Pays* Diagnostic & Preventive Diagnostic and Preventive Services – exams, cleanings, fluoride, and space maintainers 100% 100% 100% Emergency Palliative Treatment – to temporarily relieve pain 100% 100% 100% Sealants – to prevent decay of permanent teeth 100% 100% 100% Radiographs – X-rays 100% 100% 100% Basic Services Minor Restorative Services – fillings and crown repair 80% 80% 80% Endodontic Services – root canals 80% 80% 80% Periodontic Services – to treat gum disease 80% 80% 80% Oral Surgery Services – extractions and dental surgery 80% 80% 80% Other Basic Services – misc. services 80% 80% 80% Relines and Repairs – to prosthetic appliances 80% 80% 80% Major Services
TMD Treatment – treatment of the disorder of the temporomandibular joint, including related films
80% 80% 80%
80% 80% 80%
80% 80% 80%
Major Restorative Services – crowns
Prosthodontic Services – bridges, implants, dentures, and crowns over implants
Orthodontic Services
Orthodontic Services – braces 0% * When you receive services from a Nonparticipating Dentist, the percentages in this column indicate the portion of Delta Dental's Nonparticipating Dentist Fee that will be paid for those services. This amount may be less than what the Dentist charges or Delta Dental approves and you are responsible for that difference. Oral exams (including evaluations by a specialist) are payable twice per calendar year. Prophylaxes (cleanings) are payable twice per calendar year. Two additional prophylaxes are allowed per calendar year, with a history of periodontal disease. Fluoride treatments are payable twice per calendar year for Dependent children through the age of 15. 0% 0% Space maintainers for any primary tooth are payable once per area per lifetime for eligible Dependent children through the age of 15. Bitewing X-rays are payable twice per calendar year. Full mouth X-rays (which include bitewing X-rays) are payable once in any three-year period. Occlusal X-rays are payable twice in any 24 month period. Sealants or Preventive Resin Restorations - Any combination of these procedures is covered 2 times per lifetime for permanent first and second molars of eligible Dependent children through the age of 15. The surface must be free from decay and restorations. Crowns, onlays, and substructures are payable once per tooth in any three-year period. Veneers are payable on incisors, cuspids and first
bicuspids once per tooth in any three-year period, due to fracture or decay. Composite resin (white) restorations are payable on posterior teeth.
KR#60271516
Made with FlippingBook - professional solution for displaying marketing and sales documents online