Plan Description
Delta Dental Plan Of Michigan > Dental DMO
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
Division:
All Divisions
Location:
California
Employee Classes:
Full Time
Manager
Officer
General Plan Information
Annual Deductible
- Individual
$0
- Family
$0
Deductible Waived for Preventive
Yes
Annual Plan Maximum
$500
Lifetime Orthodontia Plan Maximum
$500
Reasonable & Customary
Waiting Period
30 days
Diagnostic and Preventive Services
Diagnostic and Preventive
50%
Oral Exams
80%
Bitewing X-Rays
50%
Full Mouth X-Rays
50%
Cleaning Scaling
50%
Prophylaxis Treatments
50%
Fluoride Treatments
50%
Space Maintainers
80%
Sealants
50%
Basic Services
Basic
100%
Oral Surgery: Extractions and Other Surgical Procedures
50%
Restorative: Amalgam, Synthetic Porcelain and Plastic Restorations (Fillings)
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
