Overview
For nearly 70 years, Medical Mutual of Ohio, one of the country's oldest and most trusted insurance companies, has been offering quality health insurance products at competitive
prices to serve the needs of individuals.
| SuperMed One Dental Benefits |
| Benefits |
In Network |
Out of Network |
| Benefit Period |
January 1st through December 31st |
| Dependent Age Limit |
The end of the month of the 23rd birthday |
| Annual Maximum (per member) |
$1,000 per benefit period |
| Benefit Period Deductible |
$50 per individual |
$100 per individual |
| Preventive Services |
| Oral Exams - 2 per benefit period |
100% |
80% |
| Bite Wing X-rays - 2 per benefit period |
100% |
80% |
| Prophylaxis (cleaning) - 2 per benefit period |
100% |
80% |
| Fluoride Treatment - 1 per benefit period, limited to age 19 |
100% |
80% |
| Space Maintainers - limited to age 19 |
100% |
80% |
| Emergency Palliative Treatment - includes emergency oral exam |
100% |
80% |
| Essential Services |
| Fillings |
80% after deductible |
60% after deductible |
Benefit Exclusions & Limitations
SuperMed One does not provide benefits for services, supplies, or charges for the following:
- Diagnostic X-Rays
- Minor Restorative Services
- Endodontics/Pulp Services
- Apicoectomy
- Periodontal Services
- Repairs, Relines, and Adjustments of Prosthetics
- Simple Extractions
- Impactions
- Alveoplasty
- Minor Oral Surgery Services
- General Anesthesia
- Gold Foil Restoration
- Inlays, Onlays
- Crowns
- Bridgework (Pontics & Abutments)
- Partial and Complete Dentures
- Orthodontic Diagnostic Services
- Minor Treatment for Tooth Guidance
- Minor Treatment for Harmful Habits
- Interceptive Orthodontic Treatment
- Comprehensive Orthodontic Treatment
Note: Benefits will be determined based on Medical Mutual of Ohio's medical and administrative policies and procedures. This document is only
a partial listing of dental benefits. This is not a contract of insurance. Your certificate of insurance provides a complete listing of covered services.
Apply
Click Here to Download the SuperMed One Application
Click the link above to download a printable copy of the application. This application doubles as the Medical Mutual individual health insurance
application. To select dental only, go to "Section III" on page 1, do not select any medical deductibles, and select "Dental" under "Optional Coverage."
If you run into any problems while completing the application process, please give us a call at 1-800-837-7672 or 513-247-2700,
and we'll be glad to help you out.
Submit Application
After completing the application, please send it to us by either Mail or Fax.
| Fax: |
(513) 247-2708 |
| Mail: |
Benefits Network
11300 Cornell Park Drive
Suite 280
Cincinnati, OH 45242
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