Delta Dental PPO benefits and services for SAGPH

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Principal benefits and covered services of Delta Dental PPO

Calendar Year Deductible: Plan I: $75 person/$200 per family; Plan II: $100 per person/no family maximum.

Calendar Year Maximum: Plan I: $2,500 per person; Plan II: $1,000 per person.

If your eligibility changes from Plan I to Plan II during a calendar year, any charges that were applied toward your Plan I deductible or annual maximum will apply toward the Plan II deductible and annual maximum. If your eligibility changes from Plan II to Plan I during a calendar year, the reverse is true.

Covered Services	Delta Dental PPO Network Dentists	Delta Dental Premier or Non-Network dentists
Diagnostic and Preventive Services
Oral examination - once every six months Cleanings – two per calendar year* X-rays: Bitewing – once every six months Full mouth – once every three years Fluoride treatment – children under age 19, once per calendar year Sealants – children under age 14, once every three years Biopsy/tissue examination Emergency palliative treatment Consultation – by a covered specialist Space maintainers Diagnostic casts	Plan I No deductible; 100% of dentist's fees Plan II No deductible; 100% of dentist's fees	Plan I 75% of Plan's Allowance after deductible Plan II 60% of Plan's Allowance after deductible
Basic Services
Restorative – amalgam, silicate or composite fillings Oral surgery – extractions including surgical removal of teeth Endodontics – root canal therapy Periodontics – treatment of gums and bones supporting teeth General anesthetics for oral surgery only Injectable antibiotics Addition of teeth to existing dentures Repair and rebasing of existing dentures	Plan I 75% of dentist's fees after deductible Plan II 60% of dentist's fees after deductible	Plan I 75% of Plan's Allowance after deductible Plan II 60% of Plan's Allowance after deductible
Major Services
Restorative –- gold fillings, inlays and crowns Crown replacement – if crown is over three years old Gold fillings, inlays, onlays and cast restorations – services on the same tooth limited to once every five years Fixed bridges/partial or full dentures – if required to replace lost natural teeth or an existing prosthesis which is over five years old and cannot be made serviceable	Plan I 50% of dentist's fees after deductible Plan II 50% of dentist's fees after deductible	Plan I 50% of Plan's Allowance after deductible Plan II 50% of Plan's Allowance after deductible
*Individuals receiving post-periodontal surgery maintenance are entitled to cleanings and scalings up to four times per year.