2014 Delta Premiere - Allows you to go to any dentist
Single — $34.25 Family— $67.25
To Enroll: Complete the application form (See link below) Fax the form to Danette Mitchell, AFGE 3239 Secretary or Debbie Dodd, AFGE 3239 Treasurer at: 313-672-6768. A snapshot of the enrollment form is shown on the Delta Forms page
To Withdraw: We ask that you remain a member for at least 1 year before you are eligible for a withdrawal from any plan in order to keep our premium cost at a minimun.
To enroll in Delta Premiere Contact your Local Office Representative or Danette Mitchell @ 313.333.4597 or DMitchell1222@gmail.com
BENEFIT DETAILS
Students & IRS Dependents may be included in the policy till age 25
With DeltaCare EPO Only - you have the freedom to visit any DeltaCare EPO dentist. Their is no longer a requirement to choose a primary dental office location. Referrals are not necessary to visit DeltaCare EPO specialists.
With Delta Premiere Only - Major oral surgery, periodontics, endodontics, major restorative, prosthetic and orthodontic services will not be covered until after a person is enrolled in the dental plan for 12 consecutive months.
In the event that treatment is rendered from a dentist that does not participate in any of Delta Dental's programs, the patient may be responsible for more than the percentage indicated below.
* Benefit levels may vary for procedures that fall within this category. To determine the benefits available for procedures performed or to be performed, submission of a pre-treatment estimate is advised.
For some of the covered services,the patient may be required to satisfy a waiting period.
Participating Premier or Non Participating Maximums Family Program Maximum GENMAX0001 $3000.00/year Individual Program Maximum GENMAX0001 $1000.00/year Individual Lifetime Maximum ORTHOMAX0001 $1000.00/year
* Maximum available and used apply to all services regardless of the dentist's participating status.
Routine Time Limitations: (Time limitations for other procedures may apply)
Crowns: 1 per tooth in 60 months. Exams, cleanings and fluorides: 2 in 12 months; Fluoride up to age 19. Root planing and scaling: 1 per quadrant in 24 months; occlusal guard - 1 in a lifetime. Bitewings: 1 per 12 months. Full mouth x-rays: 1 per 60 months. Orthodontics: The age limitation is noted above. Bridges and dentures: 60 month replacement limit. Coordination of Benefits: Internal (within the same Delta group): Coordination of benefits is not allowed when the other member is covered within this group. External (with another Delta group or carrier): Coordination of benefits is allowed when the other member is covered within another dental plan.
Every effort is made to provide accurate information. However, this is not a guarantee of payment. If treatment will be rendered based on Delta Dental's payment liability, we recommend you predetermine your treatment plan.
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