Delta Dental Plan of Ohio Exhibit b deltaPremier Summary of Dental Plan Benefits Muskingum College Group #1932-0001



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Delta Dental Plan of Ohio

Exhibit B

DeltaPremier

Summary of Dental Plan Benefits

Muskingum College

Group #1932-0001
The following chart indicates the services covered by Delta Dental Plan of Ohio through DeltaPremier. It also shows the percentage for coverage of Delta Dental’s allowed fee for each category and your copayment, if any:

Delta Pays: You pay:



CLASS IA






DIAGNOSTIC SERVICES: Includes oral examinations and emergency palliative treatment.

100%

0%

PREVENTATIVE SERVICES: Includes prophylaxes and topical applications of fluoride ( two per calendar year).

100%

0%

RADIOGRAPHS: X-rays, as required and in conjunction with the diagnosis of a specific condition requiring treatment.

100%

0%

CLASS IB







ORAL SURGERY: Includes extractions and other surgical dental procedure, including preoperative and postoperative care.

80%

20%

MINOR RESTORATIVE SERVICES: Includes amalgam (silver) and resin (white) fillings. Also includes relines and repairs to prosthetic appliances.

80%

20%

PERIODONTICS: Procedures to treat diseases of the gums and supporting structures of the teeth.

80%

20%

ENDODONTICS: Procedures to treat teeth with diseased or damaged nerves (for example, root canals).

80%

20%

CLASS II







MAJOR RESTORATIVE SERVICES: Includes cast restorations and crowns, but only when the teeth can not be restored with another filling material.

50%

50%

PROSTHODONTICS: Includes procedures for the construction of bridges, partial dentures and complete dentures.

50%

50%

CLASS II







ORTHODONTICS: Treatment and procedures required for the correction of malposed teeth (no age limit).

50%

50%

MAXIMUM BENEFIT:

The maximum dollar amount that this plan pays during each calendar year for each covered person is $1,000.00. For orthodontic care, the plan pays a lifetime maximum of $1,000.00 for each eligible person.
DEDUCTIBLE LIMITATIONS:

$25 deductible per person per calendar year limited to a maximum deductible of $75 per family per calendar year on Class IB and Class II benefits. The deductible does not apply to services covered at 100 percent or Class II benefits.
Customer Service toll-free number 1-800-282-0749

www.deltaentaloh.com

November 14, 2006


DELTA DENTAL

Delta Dental Plan of Ohio
How to use your dental benefits
General Information:

Group Name: Muskingum College

Program Type: DeltaPremier

Group Number: 1932-0001

Effective Date: February 1, 2000
What are my benefits? Customer Service (DASI) Phone Number

You can find this information in your Summary of 1-800-282-0749

Dental Plan Benefits. If you are unsure of what your DASI is available to take calls 24 hours

dental plan covers, you can call the Customer and a day, Monday through Saturday.

Claims Services number listed on this sheet. Through DASI, you can get benefit

levels, verify eligibility and get the



How do I find a participating dentist? names of participating dentists.

First, ask your dentist if he or she participates with Our Customer and Claims Services

Delta Dental’s dentist network called DentalPremier. Advisors are available Monday through

If you would like to find a dentist who participates with Friday 8:30 a.m. – 7:50 p.m.

DeltaPremier, you can: Eastern Time
√ verify any dentist’s participating status within Customer Service Address

DeltaPremier by calling our Customer and Written inquiries can be sent to:

Claims Services department. Our automated Attn: Customer & Claims Service

Telephone line, called DASI (Delta’s Automated Delta Dental

Service Inquiry), can provide you with a P.O. Box 30416

random list of dentists in your area. DASI can Lansing, MI 48909-7916

be reached by calling 800-282-0749.

√ access our dentist directory on our web site at Where do I send claims?



www.deltadentaloh.com If your dentist does not submit the

claim directly to Delta Dental, you



Must I see a participating dentist? should send them to:

√ Participating dentist, by contract, will accept Delta Dental

Delta Dental’s determination of payment for P.O. Box 9085

Covered services and will file claims for you. Farmington Hills, MI 48333-9085

√ This dental plan offers freedom of choice, so you What do I need when I go to the dentist?

can go to any dentist or specialist you wish. Nothing. You don’t need an ID card or

Should your chosen provider not participate a claim form to receive treatment form

in this network, you still have coverage for the dentist. However, at your first visit

covered services, but you may be subject after February 1st, it would be beneficial

To “Balance Billing”. This means that you to provide your dentist with your group

may have to pay the difference between what number for their records.

your dentist charges for services and what



Delta Dental pays.


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