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When treatment is provided by an in-network Delta Dental PPO dentist
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When treatment is provided by an out-of-network dentist (non-Delta Dental PPO dentist)
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Employees & Dependents
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Employees & Dependents
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Who's Covered |
Primary enrollee and spouse or domestic partner, as well as dependent children to age 21, or to age 25 for full-time students. |
Primary enrollee and spouse or domestic partner, as well as dependent children to age 21, or to age 25 for full-time students. |
Deductibles and Benefits Maximum |
$50 per person, $100 per family per calendar year. The benefit paid per calendar year is $1,500 per person |
$50 per person, $100 per family per calendar year. The benefit paid per calendar year is $1,500 per person |
Diagnostic and Preventive Benefits:
Oral examinations, cleanings (1),
x-rays, examinations of tissue biopsy, fluoride treatment, sealants, space maintainers, specialist consultations |
100% of Delta Dental PPO fee (no deductible applies for these services) |
100% of Delta Dental's allowed fee (no deductible applies for these services) |
| Basic Benefits: Oral Surgery (extractions), tissue removal (biopsy), fillings, root canals, periodontic (gum) treatment |
80% of Delta Dental PPO fee |
80% of Delta Dental fee |
| Crowns, jackets and cast restorations |
50% of Delta Dental PPO fee |
50% of Delta Dental fee |
| Prosthodontic Benefits: bridges, partial dentures, full dentures |
50% of Delta Dental PPO fee (subject to a maximum allowance) |
50% of Delta Dental fee (subject to a maximum allowance) |
| Orthodontic Benefits (children to age 19 only) |
50% of Delta Dental PPO fee Children: $2,000 lifetime maximum |
50% of Delta Dental fee
Children: $2,000 lifetime maximum |
