DELTA DENTAL

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Delta Dental Plan of Ohio
Exhibit B
DeltaPremier
Summary of Dental Plan Benefits
Muskingum College
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:
CLASS I
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.
CLASS II
ORAL SURGERY: Includes extractions and other surgical dental procedure, including
preoperative and postoperative care.
MINOR RESTORATIVE SERVICES: Minor restorative services, such as 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).
You pay:
100%
0%
100%
0%
100%
0%
80%
20%
80%
20%
80%
20%
80%
20%
50%
50%
50%
50%
50%
50%
CLASS III
MAJOR RESTORATIVE SERVICES: Major restorative services, such as crowns, used
when teeth cannot be restored with another filing material
PROSTHODONTICS: Includes procedures for the construction of bridges, partial dentures
and complete dentures.
CLASS IV
ORTHODONTICS: Treatment and procedures required for the correction of malposed
teeth (no age limit).
MAXIMUM BENEFIT:
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.
DEDUCTIBLE LIMITATIONS:
$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
www.deltadentaloh.com
April 14, 2009
DELTA DENTAL
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?
You can find this information in your Summary of
Dental Plan Benefits. If you are unsure of what your
dental plan covers, you can call the Customer and
Claims Services number listed on this sheet.
How do I find a participating dentist?
First, ask your dentist if he or she participates with
Delta Dental’s dentist network called DentalPremier.
If you would like to find a dentist who participates with
DeltaPremier, you can:
√ verify any dentist’s participating status within
DeltaPremier by calling our Customer and
Claims Services department. Our automated
Telephone line, called DASI (Delta’s Automated
Service Inquiry), can provide you with a
random list of dentists in your area. DASI can
be reached by calling 800-282-0749.
√ access our dentist directory on our web site at
www.deltadentaloh.com
Must I see a participating dentist?
√ Participating dentist, by contract, will accept
Delta Dental’s determination of payment for
Covered services and will file claims for you.
√ This dental plan offers freedom of choice, so you
can go to any dentist or specialist you wish.
Should your chosen provider not participate
in this network, you still have coverage for
covered services, but you may be subject
To “Balance Billing”. This means that you
may have to pay the difference between what
your dentist charges for services and what
Delta Dental pays.
Customer Service (DASI) Phone Number
1-800-282-0749
DASI is available to take calls 24 hours
a day, Monday through Saturday.
Through DASI, you can get benefit
levels, verify eligibility and get the
names of participating dentists.
Our Customer and Claims Services
Advisors are available Monday through
Friday 8:30 a.m. – 7:50 p.m.
Eastern Time
Customer Service Address
Written inquiries can be sent to:
Attn: Customer & Claims Service
Delta Dental
P.O. Box 30416
Lansing, MI 48909-7916
Where do I send claims?
If your dentist does not submit the
claim directly to Delta Dental, you
should send them to:
Delta Dental
P.O. Box 9085
Farmington Hills, MI 48333-9085
What do I need when I go to the dentist?
Nothing. You don’t need an ID card or
a claim form to receive treatment form
the dentist. However, at your first visit
after February 1st, it would be beneficial
to provide your dentist with your group
number for their records.
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