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2023 Dental Benefits

Delta Dental
Dental Plan

You have the option to enroll in our group dental plan. The benefits and your contributions are as
follows:

You are strongly encouraged to use an Benefit In Network
in- network dentist to maximize your Annual Deductible $50 / $150
benefits and minimize your out-of- Individual/Family
pocket cost. To see if your dentist is in (waived for Preventive and
the network click on Provider Network Diagnostic services)
and select the DMHO network. Annual Maximum $1,000
Preventive Services Covered at 100%
•
Oral Exams
• Cleanings
Payment to non-network providers will • X-Rays
be based on the Network fee schedule, • Fluoride Treatment
and could result in balance billing. (through age 18)
Basic Services Include Covered 80% after deductible
• Fillings
•
Emergency Visits
Dental Care Plus Customer Service • Simple Denture Repair
800-367-9466 or 513-554-1100 • Basic Oral Surgery
• Simple Extractions
• Endodontic
• Periodontic
• Sealants
Major Services Include: Covered 50% after deductible
• Complex Extractions
• Crowns
• Inlays, Onlays
• Bridgework
• Complex / Partial Denture
Orthodontic Services Covered 50%
Limited to eligible dependents $1000 individual lifetime maximum
under 19 years if age

Coverage Election Monthly Salary EE’s Hourly EE’s
Employee Only $8.87 $4.09 $2.05
Employee + Spouse $17.02 $7.85 $3.93
Employee + Children $24.14 $11.14 $5.57
Family $32.58 $15.04 $7.52

For additional plan information, please refer to the detailed plan description provided by the carrier.
In the event of a discrepancy, the carrier Pan Document shall prevail.