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Plan 1- Delta Dental PPO
DeltaPreferred Option (DPO)
is a preferred provider organization program that can reduce your out-of-pocket
expenses if you receive care from one of Delta Dental's PPO
Dentists. This program has back-up coverage through Delta Dental Premier when treatment is received from a Non-PPO
Dentist. You are also free to utilize non-Delta dentists,
however there is no protection against balance billing by providers who
do not participate with Delta Dental. Delta Dental participating providers accept Delta fees while non-participating providers may not, and may bill you for the difference between Delta Dental's payment and their charge. This is known as balance billing.
Provider Directories
Delta Dental PPO provider directories may be viewed and printed by
city or zip code from Delta Dental's web site at www.deltadentaloh.com.
You may also call Delta Dental at 1-800-524-0149 for provider information.
Delta's Automated Service Inquiry System (DASI) requires that members
enter a group number or social security number to obtain benefits and
provider information. The group number for state of Ohio members enrolled
in the Delta Dental PPO is 9273-0001.
The Benefit Feature Sheet below describes the coverage available to you
under the DeltaPreferred Option.
Delta Dental PPO
Benefit Features For
The State of Ohio
Delta Dental PPO is a point-of-service PPO administered by Delta
Dental Plan of Ohio. You can go to any licensed dentist,
but you could increase your benefits and lower your out-of-pocket costs
by going to a PPO dentist. If you don't
go to a PPO dentist, you'll be covered
by Delta Dental Premier, a managed fee-for-service
program. However, you might have to pay more. In addition, non-participating
dentists can "balance bill"
for amounts over Delta Dental's allowed fee.
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PPO
Dentist
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Delta Premier
Dentist
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Non-Participating Dentist
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Delta Dental Pays
|
You Pay
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Delta Dental Pays
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You Pay
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Delta Dental Pays
|
You Pay
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CLASS I
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| DIAGNOSTIC AND PREVENTIVE SERVICES - Includes oral examinations,
prophylaxes, topical applications of fluoride
and emergency palliative treatment. |
100%
|
0%
|
100%
|
0%
|
100%
|
0%
|
| RADIOGRAPHS - X-rays, as required and in conjunction with
the diagnosis of a specific condition requiring treatment. |
100%
|
0%
|
100%
|
0%
|
100%
|
0%
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CLASS II
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| SEALANTS - Dental sealants to prevent decay of permanent
molars (up to age 19). |
100%
|
0%
|
65%
|
35%
|
65%
|
35%
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| ORAL SURGERY - Includes
extractions and other surgical dental procedures used by dentists,
including preoperative and postoperative care. |
100%
|
0%
|
65%
|
35%
|
65%
|
35%
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| MINOR RESTORATIVE SERVICES - Includes amalgam
(silver). Also resin (white) fillings on the front surfaces of the front teeth. |
100%
|
0%
|
65%
|
35%
|
65%
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35%
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| PERIODONTICS - Procedures
to treat diseases of the gums and supporting structures of the teeth.
|
100%
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0%
|
65%
|
35%
|
65%
|
35%
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| ENDODONTICS - Procedures to treat teeth with diseased or
damaged nerves (for example, root canals). |
100%
|
0%
|
65%
|
35%
|
65%
|
35%
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CLASS III
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| MAJOR RESTORATIVE SERVICES - Includes cast restorations
and crowns, but only when the teeth
cannot be restored with another filling
material. |
60%
|
40%
|
50%
|
50%
|
50%
|
50%
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| PROSTHODONTICS - Includes procedures for the construction
of bridges, partial dentures and
complete dentures. Also includes
relines and repairs to prosthetic appliances. |
60%
|
40%
|
50%
|
50%
|
50%
|
50%
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| IMPLANTS - Includes surgical placement of implant, second-stage
surgery and abutment placement. |
60%
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40%
|
50%
|
50%
|
50%
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50%
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CLASS IV |
ORTHODONTICS - Treatment and procedures required for the
correction of malposed teeth (no age limit).
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50%
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50%
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50%
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50%
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50%
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MAXIMUM BENEFIT & DEDUCTIBLE |
MAXIMUM BENEFIT
The maximum dollar amount that this plan pays during each contract
year for each covered person is: |
$1,500
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$1,000
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$1,000
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| For orthodontic care, the plan pays a lifetime maximum of:
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$1,500
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$1,500
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$1,500
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| For implants, the plan pays a lifetime maximum of: |
$1,000
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$1,000
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$1,000
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DEDUCTIBLE LIMITATIONS
$25 deductible per person per contract
year on Class I and II benefits. The deductible
does not apply to services covered at 100 percent or Class III benefits.
Any expenses incurred by an eligible person for covered
services during the last three months of a contract year (April,
May and June) and applied to the deductible
for that contract year will also be applied to the deductible
for the following contract year.
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