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t Via: <br />=" a. <br />e ~. ~UU I Z ~ <br />a <br />qr., ~~ <br />Delta Dental PPO (Point-of-Service) <br />Summary of Dental Plan Benefits <br />For Group# 0421-0001 <br />Mayfield Village <br />This Summary of Dental Plan Benefits should be read along with your Certificate. Your Certificate provides <br />additional information about your Delta Dental plan, including information about plan exclusions and limitations. If <br />a statement in this Summary conflicts with a statement in the Certificate, the statement in this Summary applies to <br />you and you should ignore the conflicting statement in the Certificate. The percentages below are applied to Delta <br />Dental's allowance for each service and it may vary due to the dentist's network participation.* <br />Control Plan -Delta Dental of Ohio <br />Benefit Year -January 1 through December 31 <br />Covered Services - <br />Delta Dental Delta Dental Nonparticipating <br />PPO Dentist Premier Dentist Dentist <br />- . - Plan Pa s l"' ' Plan Pas Plan Pavs:* <br /> <br />Diagnostic and Preventive Services -exams;" ~'- "` ` <br />100% - ` <br />100% <br />100% <br />cleanings, fluoride, ands ace maintainers, <br />Emergency Palliative Treatment-to temporarily o <br />100 /0 0 <br />100 /0 0 <br />100 /o <br />relieve ain <br />Sealants - to revent deco of enmanent teeth _.100% _ 100% 100% <br />' Brush $io s -to detect oral cancer ~ 100%~ 100% 100% <br />"Radio ra'h¢;=X~-ra s 100% 100%0~ 100% <br />Minor Restorative Services -fillings and crown <br /> 100% 80% SO% <br />re air: __ <br />Endodontie Services.=root canals <br />100%~~ .- <br />80%~. - <br />80% <br />_. <br />Periodontic Services - to treat disease, "~ ~ ...100% _ 80%. ~ 80% <br />Oral Surgery Services -extractions and dental <br /> 100% 80% 80% <br />sur er <br />Other Basic Services - misc..services 100% . <br />-. . . 80% 80% <br />Relines and Repairs-to bridges, implants, and % <br /> <br />dentures 100 80% 80% <br />Ma'or Restorative Services -crowns 60°70 50%0 ~ ~ ~~ 50% <br />Prosthodontic Services - bridges, implants, and % _ <br /> <br />.dentures 60 50% 50% <br /> <br />Orthodontic Services -braces ... _._ - __ .. , 50% ~ ~~ ~ o ~ ° <br />Orthodontic A e Limit - "" U " "fo a e.19 _ ...U to a ~e 19 - U to a e 19 <br />* When you receive services from a Nonparticipating Dentist, the percentages in this column indicate the portion of <br />Delta Dental's Nonparticipating Dentist Fee that will be paid for those services. The Nonparticipating Dentist Fee <br />maybe less than what your dentist charges and you are responsible for that difference. <br />Oral exams (including evaluations by a specialist) are payable twice per calendar year. <br />- Prophylaxes (cleanings) are payable twice per calendar year. <br />Y People with specific at-risk health conditions may be eligible for additional prophylaxes (cleanings) or fluoride <br />treatment. The patient should talk with his or her dentist about treatment. <br />Fluoride treatments are payable twice per calendar year for people up to age 19. <br />KRM49615t47 <br />