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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.
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For specific Plan benefits, limitations and
exclusions please see your Summary Plan Document for further information
or call Delta Dental’s Customer Service Department toll-free at (888)
335-8227.
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Maximum Annual
Benefits
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$1,000 |
| Calendar Year Deductible |
Delta
Preferred Option (DPO)
None
Non-Preferred Provider (Non-DPO)
None
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| Coinsurance |
Delta Preferred Option (DPO)
The Plan will pay100% up to the Maximum
Annual Benefit of covered services of a Delta Preferred Option Provider.
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Non-Preferred Provider (Non-DPO)
The Plan will pay 50% of the Maximum
Annual Benefit of covered services of a Non-Preferred Provider. |
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| 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.
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| Limitations |
The Plan does have limitations on specific
services.
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| Exclusions |
The Plan has a specific list of services
that are not covered as eligible dental expenses.
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Please see your Summary Plan Document (Plan
Document) for greater details.
| Tri-County Schools Insurance Group also
offers, by employee group, additional options in its Dental Program.
The add-on costs are for active employees
placed on the composite, family rate structure. Please
see tiered rate schedule for active employees on a tiered rate
schedule or retirees.
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| From $1,000 Annual Maximum to $1,500 Annual
Maximum - $8.00 per employee per month. |
| From $1,000 Annual Maximum to $2,000 Annual
Maximum - $12.00 per employee per month. |
| Child Only Orthodontics, 50/50 from $500 to
$1,000 lifetime - $2.00 per employee per month. |
| Adult/Child Orthodontics from $500 to $1,000
lifetime - $3.00 per employee per month. |
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