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. Porcelain and resin facings on crowns are optional treatment on posterior teeth. Vestibuloplasty is a Covered Service. TMD treatment, manipulation under anesthesia, occlusal orthotic device, occlusal orthotic device adjustment, and unspecified TMD therapy (by report), 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. Antibiotic drug injections and nitrous oxide are Covered Services. 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 50% 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. Eligible People – All benefit-eligible employees (0004) and COBRA (4099) as defined by the University of Cincinnati who choose the Comprehensive Dental Plan with Ortho. 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. 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 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 January 1, 2021 Additional Insurance 8
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