UC Only AAUP Faculty Onboarding Binder 2022

Delta Dental PPO™ (Point-of-Service) Summary of Dental Plan Benefits For Group# 10137-0001, 1099 University of Cincinnati AAUP

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*

Diagnostic & Preventive

Diagnostic and Preventive Services – exams, cleanings, fluoride, and space maintainers

100%

Emergency Palliative Treatment – to temporarily relieve pain Sealants – to prevent decay of permanent teeth

100% 100% 100% 100% 100% 100%

Radiographs – X-rays

Basic Services

Minor Restorative Services – fillings and crown repair Oral Surgery Services – extractions and dental surgery

Other Basic Services – misc. services

Major Services

Endodontic Services – root canals

80% 80% 80% 80%

Periodontic Services – to treat gum disease Major Restorative Services – crowns Relines and Repairs – to prosthetic appliances TMD Treatment – treatment of the disorder of the temporomandibular joint, including related films

80%

Prosthodontic Services – bridges, implants, dentures, and crowns over implants 80% * 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. 80% 80%  Oral exams (including evaluations by a specialist) are payable twice per calendar year.  Prophylaxes (cleanings) are payable twice per calendar year.  People with specific at-risk health conditions may be eligible for additional prophylaxes (cleanings) or fluoride treatment. The patient should talk with his or her dentist about treatment.  Fluoride treatments are payable twice per calendar year for Dependent children through the age of 15.  Space maintainers are payable once per area per lifetime for 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 two-year period. Tomographic survey and cone beam imaging and interpretation for TMJ series and Covered Services.  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. The surface must be free from decay and restorations. The surface must be free from decay and restorations.

KR#25352842

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