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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.

Customer Service toll-free number 800-524-0149
www.deltadental.com
PPO
Dentist
Delta Premier
Dentist
Non-Participating Dentist
Delta Dental Pays
You Pay
Delta Dental Pays
You Pay
Delta Dental Pays
You Pay
CLASS I
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%
CLASS II
SEALANTS - Dental sealants to prevent decay of permanent molars (up to age 19).
100%
0%
65%
35%
65%
35%
ORAL SURGERY - Includes extractions and other surgical dental procedures used by dentists, including preoperative and postoperative care.
100%
0%
65%
35%
65%
35%
MINOR RESTORATIVE SERVICES - Includes amalgam (silver). Also resin (white) fillings on the front surfaces of the front teeth.
100%
0%
65%
35%
65%
35%
PERIODONTICS - Procedures to treat diseases of the gums and supporting structures of the teeth.
100%
0%
65%
35%
65%
35%
ENDODONTICS - Procedures to treat teeth with diseased or damaged nerves (for example, root canals).
100%
0%
65%
35%
65%
35%
CLASS III
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%
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%
IMPLANTS - Includes surgical placement of implant, second-stage surgery and abutment placement.
60%
40%
50%
50%
50%
50%
CLASS IV
ORTHODONTICS - Treatment and procedures required for the correction of malposed teeth (no age limit).
50%
50%
50%
50%
50%

50%

MAXIMUM BENEFIT & DEDUCTIBLE
MAXIMUM BENEFIT
The maximum dollar amount that this plan pays during each contract year for each covered person is:
$1,500
$1,000
$1,000
For orthodontic care, the plan pays a lifetime maximum of:
$1,500
$1,500
$1,500
For implants, the plan pays a lifetime maximum of:
$1,000
$1,000
$1,000
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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PLAN 2 - DELTAPREMIER USA->
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