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DENTAL PLAN COMPARISON FY2018 (July 1, 2017 – June 30, 2018) BENEFIT Provider Network DCP – High DCP – Basic DCP – Choice (Out of Area) Dental Care Plus DHMO Dental Care Plus DHMO Balance Value Network / DPPO Network Network $50 $150 $50 $150 Network Out-of-Network Annual Deductible (Ded) Single: Family: Plan Annual Maximum Per Covered Member: Balanced Billing Preventive Care Basic Services Major Services Orthodontia Orthodontia Lifetime Maximum Benefit (up to Age 19) $50 $150 $1,500 $750 $1,000 (Preventive services apply to Annual Maximum) (Preventive services apply to Annual Maximum) (Preventive services apply to Annual Maximum) No $0 Ded + 20% Ded + 40% 40% No $0 Ded + 50% Ded + 50% 50% $1,500 per dependent child $750 per dependent child No $0 Ded + 20% Ded + 40% 40% Yes $0 Ded + 20% Ded + 40% 40% $1,000 per dependent child DEFINITIONS Balanced Billing: If you are subject to balanced billing you will be 100% responsible for any charges considered above reasonable and customary charge for the service performed. Basic Benefits: Generally includes services such as fillings (amalgams) and simple extractions. Co-Insurance: The portion of charges that you will pay once you have met the deductible. Copay: A flat dollar amount that you pay for a service without needing to first meet a deductible. Deductible: An amount of money that the member must pay out of pocket before the plan begins paying for a service. Home Maintenance Organization (HMO): An HMO is a type of insurance plan that usually limits the coverage of care to dentists who are contracted with the carrier, in this case Dental Care Plus. There is no out-of-network coverage with the High HMO and the Basic HMO plans. Major Services: Generally includes restorative services such as crowns, bridges, implants, and dentures. Plan Annual Maximum: The maximum dollar amount in benefits paid by the plan per covered member per plan year; includes preventive, basic, and major services (if covered). Preferred Provider Organization (PPO): A PPO is a type of insurance plan that generally offers in-network and out of network coverage. However, if you do not use an in network or participating provider, you may be subject to balance billing. Note – the Choice (Out of Area) Balance Value is a narrower network in the Greater Cincinnati area compared to the DCP High/Basic DHMO network. Please verify if your Dentist is in the BVN network. Preventive Care: Generally includes two oral exams, two cleanings, and two bitewing x-rays per 12 month period. Reasonable and Customary: The reasonable and customary charge for a service is based upon the usual fee charged for the service by most dentists in a geographic area. This document is intended to provide an overview of common services only. Please refer to the applicable Summary Plan Description on CenterLink for more detailed coverage information.