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Dental Contributions Per Pay Period
Single	$2.30
Family	$9.10

A comprehensive dental plan plays an important part in assuring your overall well-being. Our plan, provided through Medical Mutual’s SuperDental program, is a Preferred Provider Organization (PPO) that offers access to one of the most extensive provider networks in Ohio and nationwide. It also gives you a high level of benefits, whether you visit an in-network or out-of-network provider.

Through the PPO Plan, you have the flexibility to receive dental care from the dentist of your choice. However, using a network dentist that has prenegotiated rates will save you money.

MEDICAL MUTUAL PREFERRED PROVIDER ORGANIZATION (PPO) PLAN

If you select a participating dentist from the Super Dental Care (SDC) network you will realize substantial savings, because network providers have agreed to accept a discounted fee schedule as payment in full, thereby reducing your out-of-pocket expenses. Using the network also provides reassurance about the level of care, since participating dentists have to meet certain standards to be included. In addition, using the network eliminates the hassle of filing claim forms. Conversely, non-participating dentists have not agreed to charge specific amounts and you will be responsible for any difference between the reasonable and customary amount and what the dentist actually charges. Out-of-network dentists will often bill you directly, requiring that you file a claim form to receive reimbursement from Medical Mutual.

PRECERTIFICATION REQUIREMENTS

Medical Mutual may require advance notice for certain more expensive services in order to receive full coverage. If you are unsure about coverage, contact Medical Mutual by calling the telephone number indicated on your ID card before you receive these services. You and your dentist should be clear about whether these services are approved under the plan before services are received.

To find a participating dentist, visit: Find-A-Dentist | Superior Dental Care or call Member Services at: 1-800-362-4700.

	Medical Mutual Dental PPO Plan
	In-Network	Out-of-Network
Calendar year maximum per member (Class I, II, III expenses)	$1,500	$1,500
Calendar year deductible per member*	$50	$50

Benefits	In-Network	Out-of-Network
Class I Services – Routine Preventive Services• Initial and periodic oral evaluations (two evaluations every 12 months) • Bitewing x-rays (two every 12 months) • Full mouth/panoramic x-rays (one every 36 months) • Diagnostic x-rays • Prophylaxis (two every 12 months) • Space maintainers (for eligible dependent children under age 16) • Topical fluoride applications (two every 12 months for eligible dependent children under age 14) • Emergency palliative treatments • Dental sealants** (one every 36 months for eligible dependent children under age 16)	100%, no deductible	100%, no deductible
Class II Services – Essential Services • Consultations/other evaluations • Amalgam or resin based composite fillings • Endodontic services • Periodontal services • Extractions • Impactions • Repairs, relines & adjustments of prosthetics • General anesthesia • IV sedation • Minor oral surgery	100%, after deductible	80%, after deductible
Class III Services – Complex Services • Inlays (1 every 5 years per tooth) • Onlays (1 every 5 years per tooth) • Crowns (1 every 5 years per tooth) • Fixed partial dentures (bridges) (1 every 5 years per unit) • Dentures*** (complete & partial) (1 every five years)	60%, after deductible	50%, after deductible
Class IV Services – Orthodontic Services • Lifetime Orthodontia Maximum	50% $1,500	50% $1,500

Benefit verification is required for any Course of Treatment exceeding $200 or involving major restorations.
* Deductible applies to Class II (Essential) & Class III (Complex) services only.
** Dental sealants are limited to eligible teeth free from decay or restorations on the occlusal surface.
*** Relining and rebasing is covered if done no less than six months after initial placement but not more than once in any 36 month period. One replacement of a temporary denture if a permanent denture is installed within 12 months of the installment of the temporary denture.