| Maximum Annual Benefits | $1,000 |
| Calendar Year Deductible | Delta Preferred Option - None or Delta Non-Preferred Option - None |
| Coinsurance | Delta Preferred Option Provider - The Plan will pay 100% up to the Maximum Annual Benefit of covered services of a Delta Preferred Option Provider. Non-Preferred Option Provider - The Plan will pay 50% of the Maximum Annual Benefit of covered services of a Non-Preferred Provider. |
| Benefits | The Plan pays a wide variety of eligible expenses. Please see your Summary Plan Document for further information or call Delta Dental's Customer Service Department, toll-free, at (888) 335-8227. |
| Limitations | The Plan does have limitations on specific services. |
| Exclusions | The Plan has a specific list of services that are not covered as eligible dental expenses. |
Tri-County Schools Insurance Group also offer, by employee group, the following additional options in its Dental programs.
For specific Plan benefits, limitations and exclusions, please see your Summary Plan Document for further information.
Add-On Cost: | No Ortho or Child Only Ortho or Adult/Child Ortho | No Ortho or Child Only Ortho or Adult/Child Ortho |
| Annual Maximum | $1,500 | $2,000 |
| Composite (Family) | $8.00 | $12.00 |
| Employee or Retiree Only | $4.00 | $6.00 |
| Employee or Retiree and One Dependent | $7.00 | $11.00 |
| Employee or Retiree and Family | $10.00 | $16.00 |
In addition, the orthodontic benefit can be increased from $500 to $1,000 in the Child Only Ortho Plan for $2.00 per month/per employee and the Adult/Child Ortho Plan for $3.00 per month/per employee.
This is an outline only to provide a overview of benefits. It does not constitute the group policy and is not a contract of insurance. This outline provides essential features of the group benefits provided. All rights with respect to the benefits of an insured person will be governed solely by the current group policy Plan Document.
