|
|
|
Plan Description
Delta Dental Plan Of Michigan > Delta Preferred Option
|
|
|
Note: This page contains a brief summary of coverage. It does not
state all provisions and limitations of the plan. The terms and provisions of
each plan, as outlined in the plan document, will determine coverage and
eligibility.
|
|
Broker Name:
|
Delta Dental Plan Of Michigan
|
|
Policy Number:
|
34512435
|
|
Original Plan Effective Date:
|
12/11/2002
|
Rate Guarantee Expiration Date:
|
12/11/2002
|
|
Plan Anniversary Date:
|
12/11/2202
|
|
Billing Cut-off Day of the Month:
|
25
|
|
Retroactive Termination Limit:
|
60
|
|
Division:
|
All Divisions
|
|
Location:
|
California
|
|
Employee Classes:
|
Full Time
Manager
Officer
|
|
|
In Network
|
Out of Network
|
General Plan Information
|
|
Annual Deductible
|
|
- Individual
|
$0
|
$0
|
|
- Family
|
$0
|
$0
|
|
Deductible Waived for Preventive
|
Yes
|
Yes
|
|
Annual Plan Maximum
|
$2,000
|
$1,500
|
|
Lifetime Orthodontia Plan Maximum
|
$1,000
|
$500
|
|
Reasonable & Customary
|
90%
|
80%
|
|
Waiting Period
|
30 days
|
60 days
|
Diagnostic and Preventive Services
|
|
Diagnostic and Preventive
|
80%
|
50%
|
|
Oral Exams
|
80%
|
50%
|
|
Bitewing X-Rays
|
80%
|
50%
|
|
Prophylaxis Treatments
|
80%
|
50%
|
|
Fluoride Treatments
|
80%
|
50%
|
|
Space Maintainers
|
80%
|
50%
|
|
Sealants
|
80%
|
50%
|
Waiting Period Information
Eligible employees are eligible as of the 1st of the month following the employee's hire date.
Termination of Coverage Information
When a plan participant is terminated from the company, the plan coverage ends on the last day of the month following the employee's termination date.
|
(per month)
|
|
Employee Cost
|
Company Cost
|
Total
|
|
Employee
|
$0
|
$15.43
|
$15.43
|
|
Employee + Spouse
|
$5.23
|
$49.32
|
$54.55
|
|
Employee + Child(ren)
|
$32.01
|
$91.02
|
$123.03
|
|
Family
|
$65.23
|
$154.23
|
$219.46
|
|
Delta Dental Plan of Michigan
Member Services
John Carpet
P.O. Box 173
Detroit, MI
80217
303-741-9300
|
|
