| Dental Benefits Summary | ||||||||||
| Premier Option B | ||||||||||
| Family Deductible | ||||||||||
| How To Use this Dental Plan | ||||||||||
| When you visit your dental provider, tell him or her you are a member of an ODS dental program. | ||||||||||
| Calendar year maximum, per member | $1,500 | |||||||||
| Calendar year deductible, per member | $50 | |||||||||
| Calendar year maximum deductible, per family | $150 | |||||||||
| Service | Benefit Amount | |||||||||
| PREVENTIVE* | 100% | |||||||||
| - | Examination/X-rays (routine exam & bitewing x-rays once every six | |||||||||
| months) | ||||||||||
| - | Prophylaxis (cleanings - once every six months) | |||||||||
| - | Fissure Sealants | |||||||||
| - | Space Maintainers | |||||||||
| BASIC | 80% | |||||||||
| - | Restorative Dentistry (treatment of tooth decay with amalgam or composit | |||||||||
| - | Oral Surgery (surgical extractions & certain minor surgical procedures) | |||||||||
| - | Endodontic (pulp therapy & root canal filling) | |||||||||
| - | Periodontics (treatment of tissues supporting the teeth) | |||||||||
| MAJOR | 50% | |||||||||
| - | Crowns | |||||||||
| - | Cast Restorations | |||||||||
| - | Denture and Bridge Work (construction or repair of fixed bridges, | |||||||||
| partials, and complete dentures) | ||||||||||
| * | Deductible waived for preventive. | |||||||||
| Advantages | ||||||||||
| * | Freedom to choose your dentist ODS is unique in that we have contracts with over 1, 800 of licensed dentists in Oregon. As the Delta Dental Plan of Oregon, employers have the option of choosing a Delta Dental Plan that provides access to over 100,000 den | |||||||||
| * | Professional Arrangements ODS has specific fee arrangements with our participating dentists in Oregon to ensure that actual charges made by the dentist do not exceed his or her accepted fees on file with ODS. We believe that the underlying unique feature | |||||||||
| * | Pre-determination As a service to our customers, your dental office can submit a pre-treatment plan to ODS on your behalf, and we will return it to them indicating the dollar allowance which will be covered by your plan before you go forward with treatmen | |||||||||
| Dependent Eligibility | ||||||||||
| Dependents are lawful spouse and unmarried dependent children to age 23, including children an employee is required to enroll due to a court or administrative order. | ||||||||||
| This is a benefit summary only. For a more detailed description of benefits, refer to your member handbook. |
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| Visit our website at www.odscompanies.com | ||||||||||
| ODS-Premden-B3X50 1/1/2005 (Rev. 3/22/2005) | ||||||||||
| LIMITATIONS | ||||||||||
| If an eligible person selects a more expensive plan of treatment than is functionally adequate, ODS will pay the applicable percentage of the maximum plan allowance for the least costly treatment. The patient will then be responsible for the remainder of | ||||||||||
| Preventive (Class I Services) | ||||||||||
| * | Diagnostic Routine examination and bitewing x-rays limited to once every six (6) months. Full mouth x-rays limited to once every (3) years. | |||||||||
| * | Preventive Prophylaxis (cleaning) or periodontal maintenance limited to once every six (6) months. Fluoride application limited to once every six (6)months. Sealant benefits are limited to the occlusal surfaces of unrestored permanent Bicuspids and mola | |||||||||
| Basic (Class II Services) | ||||||||||
| * | Oral Surgery Limited to minor surgical procedures and does not allow payment for services such as vestibuloplasty, etc. | |||||||||
| * | Restorative A separate charge for general anesthesia and/or IV sedation is not covered when used for non-surgical procedures. | |||||||||
| * | Periodontic Scaling and root planning is limited to once per quadrant in any twenty-four (24) month period. Maintenance procedure or prophylaxis (cleaning) is limited to once in a six (6) month period. | |||||||||
| Major (Class III Services) | ||||||||||
| * | Restorative If a tooth can be restored with a material such as amalgam, but another type of restoration is selected by the patient and dentist, covered expense will be limited to the cost of amalgam. Crowns and other cast restorations (including onlays a | |||||||||
| * | Prosthodontic A prosthetic device or crown will be covered only once in a five (5) year period provided the tooth has not been crowned within the past five (5) years. Specialized or personalized prosthetics are limited to the cost of standard devices. | |||||||||
| EXCLUSIONS | ||||||||||
| * | Surgical placement or removal of implants or attachments to implants. See Limitations in your | |||||||||
| member handbook for details. | ||||||||||
| * | Services covered under worker's compensation or employer's liability laws and services covered by any federal, state, county, municipality or other governmental agency, except Medicaid. | |||||||||
| * | Services with respect to congenital or developmental malformations or cosmetic reasons; including, but not limited to cleft palate, upper and lower jaw malformations, enamel hypoplasia, fluorosis and disturbance of the temporomandibular joint. | |||||||||
| * | Services for rebuilding or maintaining chewing surfaces due to teeth out of alignment or occlusion, or for stabilizing teeth. | |||||||||
| * | Services started prior to the date the individual became eligible for services under the program. | |||||||||
| * | Hypnosis, prescribed drugs, premedications or analgesia (e.g. nitrous oxide) or any other euphoric drugs. | |||||||||
| * | Hospital costs or any additional fees charged by the dentist because the patient is hospitalized. | |||||||||
| * | General anesthesia and/or IV sedation except when administered by a dentist in conjunction with covered oral surgery in his or her office. | |||||||||
| * | Plaque control and oral hygiene or dietary instructions. | |||||||||
| * | Experimental procedures. | |||||||||
| * | Missed or broken appointments. | |||||||||
| * | Orthodontic services. | |||||||||
| * | Services for cosmetic reasons. | |||||||||
| * | Claims submitted more than 15 months after the date of rendition of the services. | |||||||||
| * | All other services or supplies, not specifically covered. | |||||||||
| Visit our website at www.odscompanies.com | ||||||||||
| Insurance products provided by Oregon Dental Service. | ||||||||||
| ODS-Premden-B3X50 1/1/2005 (Rev. 3/22/2005) | ||||||||||