Delta Dental PPO™ (Point-of-Service) Summary of Dental Plan Benefits For Group# 10137-0002, 2099 University of Cincinnati Basic 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
80%
80%
80%
Emergency Palliative Treatment – to temporarily relieve pain Sealants – to prevent decay of permanent teeth
80% 80% 80% 80% 80% 80% 80% 80% 60% 60% 60% 60%
80% 80% 80% 80% 80% 80% 80% 80% 60% 60% 60% 60%
80% 80% 80% 80% 80% 80% 80% 80%
Radiographs – X-rays
Basic Services
Minor Restorative Services – fillings and crown repair Oral Surgery Services – extractions and dental surgery Relines and Repairs – to prosthetic appliances TMD Treatment – treatment of the disorder of the temporomandibular joint, including related films Other Basic Services – misc. services
Major Services
Endodontic Services – root canals
60% 60% 60%
Periodontic Services – to treat gum disease Major Restorative Services – crowns
Prosthodontic Services – bridges, implants, dentures, and crowns over implants 60% * 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. Full mouth debridement is payable once per lifetime. 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 people age 15 and under. Space maintainers are payable once per area per lifetime for people age 15 and under. 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 2-year period. Sealants are payable twice per tooth per lifetime for people age 15 and under for permanent bicuspids and molars. 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 for children ages 8 through 19. Composite resin (white) restorations are payable on posterior teeth. Porcelain and resin facings on crowns are optional treatment on posterior teeth.
KR#16106228
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