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Plan 2 - Delta Dental Premier
Delta Dental Premier is the program offered to exempt employees who live in the remaining 38
Ohio counties or out of state. DeltaPremier is a traditional fee-for-service
plan. DeltaPremier dentists have agreed
to accept Delta's usual payment as payment in full with no balance billing
of members. Nearly 3,600 Ohio dentists
participate in the DeltaPremier program. Members may also use a non-participating
dentist and receive the same level of benefits, but without the protection
against balance billing by providers.
Provider Directories
Delta Dental Premier 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 Automatic 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 Premier plan is 9273-1001.
The Benefit Features Sheet below describes the coverage available to
you under the Delta Dental Premier plan.
Delta Dental Premier
Benefit Features For
The State of Ohio
The following chart indicates the services covered by Delta
Dental Plan of Ohio through DeltaPremier
USA. It also shows the percentage of coverage of Delta Dental's allowed
fee for each category and your copayment,
if any. Nonparticipating dentists
can "balance bill" for amounts over Delta Dental's allowed fee.
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Delta Premier
Dentist
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Nonparticipating Dentist
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Delta Dental Pays
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You Pay
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Delta Dental Pays
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You Pay
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CLASS I
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DIAGNOSTIC AND PREVENTIVE SERVICES
Includes oral examinations, prophylaxes, and topical applications
of fluoride and emergency palliative
treatment. |
100%
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0%
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100%
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0%
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RADIOGRAPHS
X-rays, as required and in conjunction with the diagnosis of a specific
condition requiring treatment. |
100%
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0%
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100%
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0%
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CLASS II
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SEALANTS
Dental sealants to prevent decay of permanent molars (up to age 19).
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65%
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35%
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65%
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35%
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ORAL SURGERY
Includes extractions and other surgical dental procedures employed
by dentists, including preoperative
and postoperative care. |
65%
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35%
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65%
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35%
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MINOR RESTORATIVE SERVICES
Includes amalgam (silver) and
resin (white) fillings. |
65%
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35%
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65%
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35%
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PERIODONTICS
Procedures to treat diseases of the gums and supporting structures
of the teeth. |
65%
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35%
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65%
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35%
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ENDODONTICS
Procedures to treat teeth with diseased or damaged nerves (for example,
root canals). |
65%
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35%
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65%
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35%
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CLASS III
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MAJOR RESTORATIVE SERVICES
Includes cast restorations and crowns,
but only when the teeth can't be restored with another filling
material. |
50%
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50%
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50%
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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. |
50%
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50%
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50%
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50%
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IMPLANTS
Includes surgical placement of implant, second-stage surgery and abutment
placement. |
50%
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50%
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50%
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50%
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CLASS IV
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ORTHODONTICS
Treatment and procedures required for the correction of malposed teeth
(no age limit). |
50%
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50%
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50%
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50%
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MAXIMUM PAYMENT & DEDUCTIBLE |
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MAXIMUM PAYMENT
The maximum dollar amount that this plan pays during each contract
year for each covered person is $1,500. For orthodontic care,
the plan pays a lifetime maximum of $1,500. For implants,
the plan pays a lifetime maximum of $1,500.
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DEDUCTIBLE LIMITATIONS
$25 deductible per person
per contract year on Class IB and II benefits. The deductible
does not apply to services covered at 100 percent or Class III benefits.
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Customer Service toll-free number 800-524-0149
www.deltadentaloh.com
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