Page 9 - 2016 Enrollment
P. 9
Capsa Solutions
Dental
Dental Benefits
Coverage will be staying with Delta Dental of Ohio for 2016. Delta
Dental has a large national network of providers. Both PPO and
Premier dentists are considered to be in-network. These providers
will submit your claim form to Delta Dental and should not
balance bill you. PPO dentists typically provide greater discounts
than Premier dentists. Participating providers may be located at
www.deltadentaloh.com.
If you seek services from a non-participating dentist, you may
need to submit your own claims. Non-participating dentists may
also balance bill you (hold you responsible for the difference in the
amount they charge above Delta Dental’s reimbursement level).
Premier Non-
Dental—Delta Dental PPO Dentist Dentist Participating
Dentist
Calendar Year Deductible
Individual $25 $25 $25
Family $75 $75 $75
Calendar year maximum $2,000 per person
Diagnostic and preventive: exams, 100%; 100%; 100%;
cleanings, luoride treatments, no ded no ded no ded
x-rays, etc.
Basic: illings, endodontic services, 80% 80% 80%
periodontic services, oral surgery, after ded after ded after ded
etc.
Major: crowns, bridges, implants, 50% 50% 50%
and dentures after ded after ded after ded
Orthodontia Not covered Not Not covered
covered
9
Dental
Dental Benefits
Coverage will be staying with Delta Dental of Ohio for 2016. Delta
Dental has a large national network of providers. Both PPO and
Premier dentists are considered to be in-network. These providers
will submit your claim form to Delta Dental and should not
balance bill you. PPO dentists typically provide greater discounts
than Premier dentists. Participating providers may be located at
www.deltadentaloh.com.
If you seek services from a non-participating dentist, you may
need to submit your own claims. Non-participating dentists may
also balance bill you (hold you responsible for the difference in the
amount they charge above Delta Dental’s reimbursement level).
Premier Non-
Dental—Delta Dental PPO Dentist Dentist Participating
Dentist
Calendar Year Deductible
Individual $25 $25 $25
Family $75 $75 $75
Calendar year maximum $2,000 per person
Diagnostic and preventive: exams, 100%; 100%; 100%;
cleanings, luoride treatments, no ded no ded no ded
x-rays, etc.
Basic: illings, endodontic services, 80% 80% 80%
periodontic services, oral surgery, after ded after ded after ded
etc.
Major: crowns, bridges, implants, 50% 50% 50%
and dentures after ded after ded after ded
Orthodontia Not covered Not Not covered
covered
9
