Summary of Dental Benefits. Delta Dental PPO (Point-of-Service) Summary of Dental Plan Benefits For Group #1555-0620 Lake Erie Regional Council Midview Local Schools This Summary of Dental Plan Benefits should be read along with your Certificate. Your Certificate provides additional information about your Delta Dental plan, including information about plan exclusions and limitations. If a statement in this Summary conflicts with a statement in the Certificate, the statement in this Summary applies to you and you should ignore the conflicting statement in the Certificate. The percentages below are applied to Delta Dental’s allowance for each service and it may vary due to the dentist’s network participation.* Control Plan – Delta Dental of Ohio Benefit Year – January 1 through December 31 Covered Services – Delta Dental PPO Dentist Delta Dental Premier Dentist Nonparticipating Dentist Plan Pays Plan Pays Plan Pays* Diagnostic & Preventive Diagnostic and Preventive Services – exams, cleanings, fluoride, and space maintainers 100% 100% 100% Emergency Palliative Treatment – to temporarily relieve pain 100% 100% 100% Brush Biopsy – to detect oral cancer 100% 100% 100% Radiographs – X-ray, including TMJ films 100% 100% 100% Professional Visits – includes consultations 100% 100% 100% Caries Susceptibility Test 100% 100% 100% Pulp Vitality Test 100% 100% 100% Basic Services Minor Restorative Services – fillings and crown repair 100% 100% 100% Endodontic Services – root canals 100% 100% 100% Periodontal Maintenance – cleanings following periodontal therapy 100% 100% 100% Other Surgery Services – extractions and dental surgery 100% 100% 100% Other Basic Services – misc. services 100% 100% 100% Relines and Repairs – to bridges, implants, and dentures 100% 100% 100% Major Services Periodontic Services – to treat gum disease 80% 80% 80% Major Restorative Services – crowns 80% 80% 80% Prosthodontic Services – bridges, implants, and dentures 80% 80% 80% Orthodontic Services Orthodontic Services – braces 60% 60% 60% Orthodontic Age Limit - Dependent children up to age 25 *When you receive services from a Nonparticipating Dentist, the percentages in this column indicate the portion of Delta Dental’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. - Oral exams (including evaluations by a specialist) are payable twice per calendar year. - Prophylaxes (cleanings) ar...
