DAS/HRD Benefits - Dental and Vision Benefits

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Classes of Benefits

Class I Benefits: Diagnostic and Preventive Services
Services and procedures to evaluate existing conditions and/or to prevent dental abnormalities or disease.

Examinations
Initial, periodic, and emergency examinations.

Prophylaxes
Teeth cleaning and polishing.

Fluoride Treatments
Topical application for cavity prevention up to age 19 and age 55 or older.

Emergency Palliative Treatment
Emergency treatment to temporarily relieve pain.

Radiographs
X-rays as required for routine care or as necessary for the diagnosis of a specific condition.

Sealants
Up to age 19.

Class II Benefits: Basic Restorative, Periodontics and Oral Surgery Services

Minor restorative services, such as amalgam (silver) and resin (white) fillings. With the exception of the frontal surfaces of the front teeth, white fillings are considered cosmetic. You will be responsible for the difference in cost between amalgam and white fillings if you elect this option.

Sealants up to age 14 (permanent molars).

Oral Surgery Services
Extractions and dental surgery, including pre and post-operative care.

Endodontic Services
The treatment of teeth with diseased or damaged nerves (for example, root canals).

Periodontic Services
The treatment of diseases of the gums and supporting structures of the teeth. This includes periodontal maintenance following active therapy (periodontal prophylaxis).

Class III Benefits: Major Restorative and Prosthodontic Services
Services and appliances that replace missing natural teeth (such as bridges, partial dentures, and complete dentures).

Major restorative services, such as crowns, used when teeth cannot be restored with another filling material. One (1) per tooth every 60 months.

Relines and repairs to bridges, partial dentures, and complete dentures. Sixty (60) month replacement limit.

Dental implants and abutment placement. There is a $1,000 lifetime maximum on dental implant services.

Class IV Benefits - Orthodontic Services
Services, treatment, and procedures to correct malposed teeth. No age limit.

Class IV services have a maximum to the benefits that you can receive in your lifetime. Your benefit amount is dependent upon which dental plan you have available go you and the type of provider you choose. Please see the chart below.

Summary of Dental Plan Benefits
Delta Dental offers two plan options for exempt State of Ohio employees. You may chose either plan no matter where you live.

The chart below indicates what percent of each of the classes of treatments are covered by each of the dental plans. Both dental plans are subject to a $25 annual deductible. The deductible does not apply to diagnostic and preventive (Class I) or orthodontic (Class IV) services.

	Plan 1: Delta Dental PPO			Plan 2: Delta Dental Premier
	Delta Dental PPO Dentist	Delta Premier Dentist	Non-Delta Dentist	Delta Premier Dentist	Non-Delta Dentist
Maximum Annual Benefit Per Person	$1,500	$1,000	$1,000	$1,500	$1,500
Percent of Class I Treatments Covered	100%	100%	100% R&C*	100%	100% R&C*
Percent of Class II Treatments Covered	100%	65%	65% R&C*	65%	65% R&C*
Percent of Class III Treatments Covered - Implants**	60%	50%	50% R&C*	50%	50% R&C*
Percent of Class IV Treatments Covered	50% up to $1,500 lifetime maximum	50% up to $1,500 lifetime maximum	50% R&C* up to $1,500 lifetime maximum	50% up to $1,500 lifetime maximum	50% R&C* up to $1,500 lifetime max.

* Delta Dental will pay up to the allowed amount, or the "Reasonable and Customary" charge for providers in your area. You can be balance billed by non-Delta providers for any amount that exceeds the allowable amount. Network providers cannot balance bill you for the difference between their charge and Delta Dental's' allowed amount.
** Dental implants have a separate $1,000 lifetime maximum.

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PLAN 1 - DELTAPREFERRED OPTION USA->


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