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c <br />Delta Dental of Ohio <br />Dental Benefit Highlights for <br />Mayfield Village #0421 <br />Diagnostic <br />Delta <br />Delta <br />Delta Dental PPO"' (Point -of- <br />Dental <br />Dental Nonparticipating <br />Service) <br />PPOTM <br />Premier* Dentist <br />100% <br />Dentist <br />Dentist <br />Coverage effective April 1, 2022 <br />Pian Pas <br />Plan Pas Plan Pays* <br />Diagnostic <br />Diagnostic and Preventive Services - <br />exams, cleanings, fluoride, and space <br />100% <br />100% <br />100% <br />maintainers <br />Emergency Palliative Treatment - to <br />100% <br />100% <br />100% <br />temporarily relieve pain <br />Sealants - to prevent decay of <br />100% <br />100% <br />100% <br />permanent teeth <br />Brush Biopsy - to detect oral cancer <br />10016 <br />100% <br />100% <br />Radio ra hs - X -res <br />Basic <br />100% <br />Services <br />100% <br />100% <br />Minor IRestorative Services - fillings <br />100% <br />80% <br />80% <br />and crown repair <br />Endodontic Services - root canals <br />100% <br />80% <br />so;;— <br />0%Periodontic <br />PeriodonticServices - to treat gum <br />100% <br />80% <br />80% <br />disease <br />Oral Surgery Services - extractions <br />100% <br />80% <br />80% <br />and dental surgery <br />so% <br />80% <br />Other Basic Services - misc. services <br />100% <br />Relines and Repairs - to prosthetic <br />100% <br />80% <br />80% <br />ap fiances Major <br />a'or Restorative Services - crowns <br />60%'SO%SO% <br />rosthodontic Services - bridges, <br />ri <br />mplants, dentures, and crowns over <br />60% <br />50% <br />50% <br />im !ants <br />Orthodontic <br />Orthodontic Services - braces <br />50% <br />SO% <br />50% <br />Orthodontic Age Limit - <br />through <br />through <br />through age 16 <br />age 18 <br />age 18 <br />and under <br />and under <br />and under <br />When you receive services from a Nonparticipating Dentist, me percentages ,, -- <br />column indicate the portion of Delta Dental's Nonparticipating Dentist Fee that will be <br />paid for those services. This amount maybe less than what the Dentist charges or Delta <br />Dental approves and you are responsible for that difference. <br />Maximum Payment - $1,750 per person total per Benefit Year on all services <br />except orthodontic services. $1,000 per person total per lifetime on <br />orthodontic services. <br />Deductible - $25 Deductible per person total per Benefit Year limited to a <br />maximum Deductible of $75 per family per Benefit Year. The Deductible does <br />not apply to diagnostic and preventive services, emergency palliative <br />treatment brush biopsy, X-rays sealants and orthodontic services. <br />Note - This document is only intended to provide a brief description ofyour <br />benefits. Please refer to your Certificate and summary for a complete description <br />of benefits, exclusions, and limitations. <br />April 1, 2022 <br />& DELTA DENTAL <br />Welcome to Ohio's largest dental <br />benefits family! <br />As a member of Delta Dental of Ohio, <br />you have access to the nation's largest <br />dental networks: Delta Dental PPO and <br />Delta Dental Premier. <br />• It's easy to find a dentist! Four out of <br />five dentists nationwide participate in <br />our network. <br />• You have superior access to care and <br />fee savings because of our <br />agreements with participating <br />dentists. <br />• Our dentists cannot balance bill you, <br />which means more money in your <br />pocket! <br />• No troublesome paperwork! Network <br />dentists will fill out and file your <br />claims. <br />• Pay only your copayments and/or <br />deductibles when you receive care <br />from network dentists -- there are no <br />hidden fees. <br />• You can still visit nonparticipating <br />dentists, but you may be billed the full <br />amount at the time of service and <br />then have to wait to be reimbursed. <br />Quality Dental Program <br />With our quick and accurate claims <br />processing, we pay more than 90% <br />of claims in 10 days or less. Delta <br />Dental also offers world-class <br />customer service from our <br />BenchmarkPortal Certified Center of <br />Excellence call center. <br />Online Access <br />Our online Member Portal lets you <br />access your dental plan securely over <br />the Internet. You can find a dentist, <br />check benefits, select paperless notices, <br />review claims and amounts used toward <br />maximums, print ID cards, and more -- all <br />at your own convenience. <br />A Healthy Smile <br />Keep your smile healthy with dental <br />benefits from Delta Dental. Your smile is <br />a good indicator of your health. Did you <br />know that your dentist can detect up to <br />120 different diseases, including diabetes <br />and heart disease? Early detection is one <br />of the best ways to prevent further <br />complications. <br />Questions? <br />If you have questions, please call our <br />Customer Service team at 800-524- <br />0149 (TTY users call 711) or look online <br />at httr)s•//www oeftaDentalOH.com, <br />0421-0001 <br />