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Delta Dental of Ohio- Dental Benefit Highlights for Mayfield Village #0421 Delta Dental PPO (Point-of-Service) Delta Dental Delta Dental Premier . Non- participating - PPO Dentist Dentist Dentist Coverage effective April 1, 2017 Plan. Pa s Plan Pas * Plan Pa s ~.. Diagnostic and Preventive Services -exams, 100%. 100% 100% sleanin s, fluoride, ands ace maintainers . Emergency Palliative Treatment - to 100% 100% 100% tem oraril relieve ain Sealants - to revent deca of ermanent teeth 100% 100% 100% Brush Bio s - to detect oral cancer 100% 100% 100% Radio ra hs - X-ra s 1.00% . 100% 100% Minor Restorative Services -fillings and crown ~ 100% - - 80% 80% re air • Endodontic Services -root canals 100% 80% 80% Periodontic Services - to treat um disease .900% ~ 80%. 80% Oral Surgery Services -extractions and dental 100% 80% 80% sur e Other Basic Services -misc. services '' 1D0% .80% 80% Relines and Repairs - to bridges, implants, and 100% 80% 80% dentures Ma'or Restorative Services -crowns ..60% 50% 50% Prosthodontic Services -bridges, implants, ~ ~ ~ 60% • 50%' 50% and dentures • ... Orthodontic Services -braces 50% ~ 50°/a 50% Orthodontic A e Limit - ~ Up to a e 79 '• U to a e:19 U to age 19 * When you receive services from a Nonparticipating Dentist, the percentages in this column indicate the portion of Delta Denfal's Nonparticipating Dentist Fee that will be paid for those services. The Nonparticipating Dentist Fee may be less than what your dentist charges and you are responsible for that difference. Maximum Payment - $1,750 per person total per Benefit Year on all services except orthodontic services. $1,000 er erson total er lifetime on orthodontic services. Deductible - $25 Deductible per person total per Benefit Year limited to a maximum Deductible of $75 per family per Benefit Year. The Deductible does not apply to diagnostic and preventive services, emergency palliative treatment, brush biopsy, X-rays, sealants, and orthodontic services. Note -This document is only intended to provide a brief description of your benefits. Please refer to your Cenrficafe and summary for a complete description of benefits, exclusions, and limitations. Welcome to Ohio's largest dental benefds family! As a member of Delta Dental of Ohio, you have access to the nation's largest dental networks: Delta Dental PPO and Delta Dental Premier. • It's easy to find a dentist! Four out of five dentists nationwide participate in our network. • You have superior access to care and fee savings because of our agreements .with partidpating dentists. • Our dentists cannot balance bill you, which means more money in your pocket! • No troublesome paperwork! Network dentists will fill out and file your claims. • Pay only your copayments and/or deductibles when you receive care from network dentists -there are no hidden fees. • You can still visit nonparticipating dentists, but you may be billed the full amount at the time of service and then have to wait to be reimbursed. Quality Dental Program With our quick and accurate claims processing, we paymore than 90% ofclaims in 10 days or less. Delta Dental also offers world-class customer service from our Certified Center of Excellence call center, as awarded by Benchmark Portal. Online Access Our online Consumer Toolkit lets you acx;ess yourdentalplansecurelyoverthelntemet. You can find a dentist, check benefits, select paperiess notices, review daims and amounts used toward maximums, print ID cards, and more - all at your own convenience. A Healthy Smile Keep your smile healthy with dental benefits from Delta Dental. Your smile is a good indicator of your health. Did you know that your dentist can detect up to 120 different diseases, induding diabetes and heart disease? Early detection is one of the best ways to prevent further complications. Questions? If you have questions, please call our Customer Service team at (800) 524-0149 (TTY users call 711) or look online at www. DeltaDentalOH.com. April 1, 2017 0421-0001