Delta Dental PPO/Dental Plan Specialist Summary
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Delta Dental Premier® Dentist and Nonparticipating Dentist
Oral exams (including evaluations by a specialist) are payable twice per calendar year.
Prophylaxes (cleanings) are payable twice per calendar year.
People with specific at-risk health conditions may be eligible for additional prophylaxes (cleanings) or fluoride treatment. The patient should talk with his or her Dentist about treatment.
Fluoride treatments are payable twice per calendar year with no age limit.
Bitewing X-rays are payable twice per calendar year and full mouth X-rays (which include bitewing X-rays) or a panorex are payable once in any three-year period.
Sealants are payable once per tooth per lifetime for first permanent molars for people age eight and under and second permanent molars for people age 13 and under. The surface must be free from decay and restorations.
Composite resin (white) restorations are payable on posterior teeth.
Porcelain and resin facings on crowns are optional treatment on posterior teeth.
Implants are payable once per tooth in any five-year period. Implant related services are Covered Services.
Crowns over implants are payable once per tooth in any five-year period. Services related to crowns over implants are Covered Services.
Having Delta Dental coverage makes it easy for you to get dental care almost everywhere in the world! You can now receive expert dental care when you are outside of the United States through our Passport Dental program. This program gives you access to a worldwide network of Dentists and dental clinics. English-speaking operators are available around the clock to answer questions and help you schedule care. For more information, check our website or contact your benefits representative to get a copy of our Passport Dental information sheet. Maximum Payment – $1,200 per Member total per Benefit Year on all services. Deductible – Delta Dental PPO™ Dentist - None.
Delta Dental Premier® Dentist or Nonparticipating Dentist - $50 Deductible per Member total per Benefit Year limited to a maximum Deductible of $100 per family per Benefit Year. The Deductible does not apply to diagnostic and preventive services, emergency palliative treatment, brush biopsy, and X-rays. Deductible Carry Forward – Any expenses incurred by a Member for Covered Services during the last three months of a Benefit Year and applied to the Deductible for that Benefit Year will also be applied to the Deductible for the following Benefit Year.
Waiting Period – Enrollees who are eligible for Benefits are covered on the first day of the month after hire or completion of a probationary period.
Eligible People – All administrative staff, part-time and full-time bus drivers, all employees within the bargaining unit and full-time support staff working 40 hours per week (0001) and retirees (0002) who choose the dental plan and COBRA (Consolidated Omnibus Budget Reconciliation Act of 1985) enrollees (0099). Also eligible at your option are your legal spouse and your dependent children to the end of the calendar year in which they turn 19 and your dependent unmarried children to the end of the calendar year in which they turn 25 if a full-time student and eligible to be claimed by you as a dependent under the U.S. Internal Revenue Code during the current calendar year.
Enrollees and dependents choosing this plan are required to remain enrolled for a minimum of 12 months. Should an Enrollee or Dependent choose to drop coverage after that time, he or she may not re-enroll prior to the date on which 12 months have elapsed. Dependents may only enroll if the Enrollee is enrolled (except under COBRA) and must be enrolled in the same plan as the Enrollee. An election may be revoked or changed at any time if the change is the result of a qualifying event as defined under Internal Revenue Code Section 125. Coordination of Benefits – If you and your Spouse are both eligible to enroll in This Plan as Enrollees, you may be enrolled together on one application or separately on individual applications, but not both. Your Dependent Children may only be enrolled on one application. Delta Dental will not coordinate Benefits between your coverage and your Spouse's coverage if you and your Spouse are both covered as Enrollees under This Plan. Benefits will cease on the last day of the month in which your employment is terminated. Customer Service Toll-Free Number: 800-***-**** (TTY users call 711) https://www.DeltaDentalIN.com
Contract Start Date: January 1, 2023
Document Creation Date: August 14, 2023
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