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:
DIAGNOSTIC SERVICES: Includes oral examinations and emergency palliative treatment.
PREVENTATIVE SERVICES: Includes prophylaxes and topical applications of fluoride ( two per calendar year).
RADIOGRAPHS: X-rays, as required and in conjunction with the diagnosis of a specific condition requiring treatment.
ORAL SURGERY: Includes extractions and other surgical dental procedure, including preoperative and postoperative care.
MINOR RESTORATIVE SERVICES: Includes amalgam (silver) and resin (white) fillings. Also includes relines and repairs to prosthetic appliances.
PERIODONTICS: Procedures to treat diseases of the gums and supporting structures of the teeth.
ENDODONTICS: Procedures to treat teeth with diseased or damaged nerves (for example, root canals).
MAJOR RESTORATIVE SERVICES: Includes cast restorations and crowns, but only when the teeth can not be restored with another filling material.
ORTHODONTICS: Treatment and procedures required for the correction of malposed teeth (no age limit).
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.
$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
November 14, 2006
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