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. Vestibuloplasty, bone replacement graft for ridge preservation (per site), and TMD are Covered Services. Full and partial dentures are payable once in any three-year period. Bridges are payable once in any three-year period. Implants are payable once per tooth in any three-year period. Implant related services are Covered Services. Crowns over implants are payable once per tooth in any three-year period. Services related to crowns over implants are Covered Services. Inhalation of nitrous oxide/analgesia and therapeutic parenteral drugs are Covered Services without limitation. Occlusal guards, repair and/or reline and adjustments of occlusal guards are covered once in any five-year period. Occlusal adjustments are covered once in any three-year period. 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. 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. Having Delta Dental coverage makes it easy for you to get dental care almost everywhere in the world! You can now receive expert dental care when you are outside of the United States through our Passport Dental program. This program gives you access to a worldwide network of dentists and dental clinics. English-speaking operators are available around the clock to answer questions and help you schedule care. For more information, check our Web site or contact your benefits representative to get a copy of our Passport Dental information sheet. Maximum Payment – $2,000 per person total per Benefit Year on all services except orthodontic services. $2,000 per person total per lifetime on orthodontic services. Payment for Orthodontic Service – When orthodontic treatment begins, your Dentist will submit a payment plan to Delta Dental based upon your projected course of treatment. In accordance with the agreed upon payment plan, Delta Dental will make an initial payment to you or your Participating Dentist equal to Delta Dental's stated Copayment on 30% of the Maximum Payment for Orthodontic Services as set forth in this Summary of Dental Plan Benefits. Delta Dental will make additional payments as follows: Delta Dental will pay 60% of the per monthly fee charged by your Dentist based upon the agreed upon payment plan provided by your Dentist to Delta Dental. Deductible – $50 Deductible per person total per Benefit Year limited to a maximum Deductible of $150 per family per Benefit Year. The Deductible does not apply to diagnostic and preventive services, emergency palliative treatment, X- rays, sealants, and orthodontic services. Waiting Period – Enrollees who are eligible for Benefits are covered on the first of the month following 28 days of active employment. Eligible People – All benefit-eligible employees (0004) and COBRA (4099) as defined by the University of Cincinnati who choose the Comprehensive Dental Plus Ortho Plan. Also eligible are your Spouse or Domestic partner and your Children to the end of the month in which they turn 26, including your Children who are married, who no longer live with you, who are not your Dependents for Federal income tax purposes, and/or who are not permanently disabled. Enrollees and dependents choosing this dental plan are required to remain enrolled for a minimum of 12 months. Should an Enrollee or Dependent choose to drop coverage after that time, he or she may not re-enroll prior to the date on which 12 months have elapsed. Dependents may only enroll if the Enrollee is enrolled (except under COBRA) and must be enrolled in the same plan as the Enrollee. An election may be revoked or changed at any time if the change is the result of a qualifying event as defined under Internal Revenue Code Section 125. Coordination of Benefits – If you and your Spouse or Domestic partner are both eligible to enroll in This Plan as Enrollees, you may be enrolled together on one application or separately on individual applications, but not both. Your Dependent Children may only be enrolled on one application. Delta Dental will not coordinate benefits between your coverage and your Spouse's coverage if you and your Spouse are both covered as Enrollees under This Plan.
Benefits will cease Benefits will cease on the last day of the month in which employment ends.
Customer Service Toll-Free Number: 800-524-0149 (TTY users call 711) https://www.DeltaDentalOH.com Contract Start Date: January 1, 2021 Document Creation Date: October 5, 2021
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