Master Agreement 2005 - State Employment Relations Board

prosthodontic appliances
• Sealants, oral hygiene instruction and dietary
instruction
• Plaquecontrol programs
• Myofunctional therapy
• Treatmentfordisturbance of the temporomandibular
joint
• Procedures, appliances or restorations necessary
to increase vertical dimension and/or restore or
maintain theocclusion–such procedures include,
but are not limited to, equilibration, periodontal
splinting, restoration of tooth structure lost from
attrition and restoration of malalignment of the
teeth
• All other services not specified.
6. Limitations
• Full-mouth X-rays are a benefit once in a threeyear
period.
• Bitewing X-rays are a benefit once in each six
months.
• Prophylaxis is a benefit once in each six months.
• Goldrestorations are provided when amalgams,
silicates or plastics cannot satisfactorily restore a
tooth.
• Prosthodontics and crowns are a benefit once in
any five-year period.
• Theallowance for a standard prosthodontic
appliance will be allowed toward the cost of an
implant.
7. Predetermination of Benefits
If other than brief and routine dental services are
needed, an Attending Dentist’s Statement (claim
form) listing the proposed services should be submitted
to Delta Dental Plan of Ohio in advance of
the dentist completing such services. The Predetermination
of Benefits procedure will enable Delta
Plan of Ohio to verify eligibility and state the
amount of benefit payable by your program.
Article 808
Vision Care Insurance
Effective January 1, 1998, or as soon thereafter as feasible,
and for the duration of this Agreement, the following vision
care coverage shall be provided at Board expense for all
members of the bargaining unit.
Prepaid Program
(Provides benefits through participating and non-participating
providers)
ParticipatingProviders
Exam ....................................$10copayment
Materials ................................$10copayment
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