Payment for Orthodontic Service. When orthodontic treatment begins, your Dentist will submit a payment plan to Delta Dental based upon your projected course of treatment. In accordance with the agreed upon payment plan, Delta Dental will make an initial payment to you or your Participating Dentist equal to Delta Dental's stated Copayment on 30% of the Maximum Payment for Orthodontic Services as set forth in this Summary of Dental Plan Benefits. Delta Dental will make additional payments as follows: Delta Dental will pay 60% of the per monthly fee charged by your Dentist based upon the agreed upon payment plan provided by your Dentist to Delta Dental. Deductible – None.
Payment for Orthodontic Service. When orthodontic treatment begins, your Dentist will submit a payment plan to Delta Dental based upon your projected course of treatment. In accordance with the agreed upon payment plan, Delta Dental will make an initial payment to you or your Participating Dentist equal to Delta Dental's stated Copayment on 30% of the Maximum Payment for Orthodontic Services as set forth in this Summary of Dental Plan Benefits. Delta Dental will make additional payments as follows: Delta Dental will pay 80% of the per monthly fee charged by your Dentist based upon the agreed upon payment plan provided by your Dentist to Delta Dental. Deductible – Delta Dental PPO™ Dentist - $25 Deductible per person total per Benefit Year limited to a maximum Deductible of $75 per family per Benefit Year. The Deductible does not apply to oral exams (except for detailed problem focused exams and limited re- evaluations), preventive services, X-rays, sealants, cleaning and inspection of a partial and complete denture, and orthodontic services. Delta Dental Premier® Dentist or Nonparticipating Dentist - $50 Deductible per person total per Benefit Year limited to a maximum Deductible of $150 per family per Benefit Year on all general services and harmful habit appliances. Waiting Period – Enrollees who are eligible for dental benefits are covered Employees are eligible for benefits following 30 days worked. Eligible People – Any full-time or part-time employee who works 20 hours or more in a week is eligible for benefits. Also eligible are your Spouse and your Children to the end of the month in which they turn 26, including your Children who are married, who no longer live with you, who are not your Dependents for Federal income tax purposes, and/or who are not permanently disabled. Coordination of Benefits –If you and your Spouse are both eligible to enroll in This Plan as Enrollees, you may be enrolled as both an Enrollee on your own application and as a Dependent on your Spouse's application. Your Dependent Children may be enrolled on both your and your Spouse's applications as well. Delta Dental will coordinate benefits between your coverage and your Spouse's coverage. Benefits will cease at the end of the month in which terminated. If you become divorced off the plan, you will be terminated on the date of termination. Customer Service Toll-Free Number: 000-000-0000 (TTY users call 711) xxxxx://xxx.XxxxxXxxxxxXX.xxx
