Principal benefits and covered services of Delta Dental PPO
Calendar Year Deductible: $25 person/$50 per family Calendar Year Maximum: $2,000 per person
Covered Services
Delta Dental PPO Network Dentists
Delta Dental Premier
Non-Network dentists
Diagnostic and Preventative Services
Oral examination - once every six months
Cleanings – two per calendar year
X-rays:
Bitewing – once every six months
Full mouth – once every five years
Fluoride treatment – children under age 19, once per calendar year
Biopsy/tissue examination
Emergency palliative treatment
Space maintainers
Study models
Sealants - children under age 14, once every three years
80% of DPO approved fees after deductible
80% of dentist's filed fees after
deductible
80% of Plan's Allowance after
deductible
Basic Services
Restorative - amalgam fillings
Oral surgery – extractions including surgical removal of teeth
Endodontics – root canal therapy
Periodontics – treatment of gums and bones supporting teeth
General anesthetics
Injectable antibiotics
Addition of teeth to existing dentures
Repair and rebasing of existing dentures
80% of DPO approved fees after deductible
80% of dentist's filed fees after
deductible
80% of Plan's Allowance after
deductible
Major Services
Restorative - gold fillings, inlays and crowns
Crown replacement - of crown is over three years old
Gold filling replacement - if filling is over five years old
Fixed bridges/partial or full dentures - if required to replace natural teeth or an existing prosthesis which is over five years old and cannot be made serviceable
80% of DPO approved fees after deductible
80% of dentist's filed fees after deductible
80% of Plan's Allowance after deductible
Orthodontia: Coverage is for children up to age 19 (students to age 23). Plan pays 50% of dentist’s fee up to a lifetime maximum payment of $1,000 per child. The annual deductible and the calendar year maximum do not apply to the orthodontia benefit.
Please refer to your Evidence of Coverage for limitations on these benefits.
