Summary Plan of Benefits
Plan Provisions and Exclusions
- MVP Bronze, Silver, and Gold Plans have provisions and exclusions that may impact eligibility for enrollee benefits.
- Employees must sign the appropriate employee application.
- Does not qualify as insurance
- Notice: All Non-Network Providers involved in the emergency services or the legally required Continuum of Care will be accepted, and Providers will be paid at Network contractual rates.
Benefit Exclusions:
- Treatment relating to a covered person: taking part in any war or act of war (including service in the armed forces), commission of or attempt to commit a felony, an act of terrorism, or participating in an illegal occupation, riot or insurrection
- Sickness or Injury sustained while on active duty in the armed forces of any country. This does not include Reserve or National Guard duty for training except if deployed on active duty
- Services, treatment or loss rendered in any Veterans Administration or Federal Hospital, except if there is a legal obligation to pay
- Surgery and treatment, procedures, products, or services that are experimental or investigative
- Suicide
Benefit Exclusions:
- Surgery to correct vision or hearing, unless a result of a covered Injury, medically necessary surgery for glaucoma, cataracts or other sickness or injury
- Dental care, dental x-rays, or dental treatment
- Gastric or intestinal bypass services including lap banding, gastric stapling, and other similar procedures to facilitate weight loss; the reversal, or revision of such procedures; or services required for the treatment of complications from such procedures. This exclusion does not apply to completion of a weight reduction program that may be payable under the Health Screening benefit;
- Rest cures or custodial care, or treatment of sleep disorders
- Cosmetic surgery (exceptions for some reconstructive or illness procedures):
- Workman’s Compensation injuries and illnesses
- Sex transformation/surgery
Armed forces
Sickness or Injury
Surgery and treatment
Dental care
Cosmetic surgery
Employer Group MVP Plan Cost
Delta Dental PPO TM
Preventive & Diagnostic 100%
- Exams, Cleanings, Bitewing x-rays (each subject to frequency limitations)
- Fluoride Treatment (subject to frequency limitations, children to age 19)
- Full Mouth X-Rays
- Space Maintainers
Calendar Year Maximum (per person) $1,500
Calendar Year Deductible (waived on Preventive & Diagnostic)
- Per Person $50
- Family Aggregate Deductible $100
Crowns & Prosthodontics 50%
- Crowns, Gold Restorations (over natural teeth)
- Bridgework
- Full & Partial Dentures; Repair of Dentures
Remaining Basic 80%
- Fillings, Simple Extractions
- Periodontics; Endodontics (root canal)
- Oral Surgery; Periodontal Maintenance
- Sealants
Delta Dental VSP Vision
