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*Please refer to your Summary Plan Description for limitations on these benefits. Some examples of limitations on services are the number of cleanings and oral exams covered in a plan year, and time limitations on filling and crown replacements.
| When treatment is provided by | In-Network Delta Dental PPO Network | In-Network Delta Dental Premier Network | Out-of-Network Non-Delta Dental Dentists |
|---|---|---|---|
| Who's Covered | Employee and spouse as well as dependents to age 26. | Employee and spouse as well as dependents to age 26. | Employee and spouse as well as dependents to age 26. |
| Deductibles and Benefits Maximum | $50 per person, $100 per family per plan year. The maximum benefit paid per plan year is $1,500 per person. | $100 per person, $200 per family per plan year. The maximum benefit paid per plan year is $1,250 per person. | $100 per person, $200 per family per plan year. The maximum benefit paid per plan year is $1,250 per person. |
| Diagnostic and preventive benefits*-oral examinations, cleanings, x-rays, examinations of tissue biopsy, fluoride treatment, space maintainers, specialist consultations | 100% of dentist's allowed fee (no deductible applies for these services) | 100% of Delta Dental's allowed 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, sealants | 80% of dentist's allowed fee | 75% of Delta Dental's allowed fee | 70% of Delta Dental's allowed fee |
| Crowns, jackets and other cast restorations* | 80% of dentist's allowed fee | 75% of Delta Dental's allowed fee | 70% of Delta Dental's allowed fee |
| Prosthododontic benefits* - bridges, partial dentures, full dentures | 50% of Delta Dental's allowed fee | 50% of Delta Dental's allowed fee | 50% of Delta Dental's allowed fee | Orthodontic benefits*- for adults and eligible dependent children | N/A | N/A | N/A |
| TMJ benefit * | 50% of dentist's allowed fee (subject to a $500 lifetime maximum per person) | 50% of Delta Dental's allowed fee (subject to a $300 lifetime maximum per person) | 50% of Delta Dental's allowed fee (subject to a $250 lifetime maximum per person) |
| Implant benefit* | 50% of dentist's allowed fee (subject to a $1,000 lifetime maximum per person) | 50% of Delta Dental's allowed fee (subject to a $750 lifetime maximum per person) | 50% of Delta Dental's allowed fee (subject to a $500 lifetime maximum per person) |
| Crowns, jackets and other cast restorations* | 80% of dentist's allowed fee | 75% of Delta Dental's allowed fee | 70% of Delta Dental's allowed fee |
| When treatment is provided by | In-Network Delta Dental PPO Network | In-Network Delta Dental Premier Network | Out-of-Network Non-Delta Dental Dentists |
|---|---|---|---|
| Who's Covered | Employee and spouse as well as dependents to age 26. | Employee and spouse as well as dependents to age 26. | Employee and spouse as well as dependents to age 26. |
| Deductibles and Benefits Maximum | $50 per person, $100 per family per plan year. The maximum benefit paid per plan year is $2,000 per person. | $100 per person, $200 per family per plan year. The maximum benefit paid per plan year is $1,500 per person. | $150 per person, $250 per family per plan year. The maximum benefit paid per plan year is $1,000 per person. |
| Diagnostic and preventive benefits*-oral examinations, cleanings, x-rays, examinations of tissue biopsy, fluoride treatment, space maintainers, specialist consultations | 100% of dentist's allowed fee (no deductible applies for these services) | 100% of Delta Dental's allowed 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, sealants | 80% of dentist's allowed fee | 75% of Delta Dental's allowed fee | 70% of Delta Dental's allowed fee |
| Crowns, jackets and other cast restorations* | 80% of dentist's allowed fee | 75% of Delta Dental's allowed fee | 70% of Delta Dental's allowed fee |
| Prosthododontic benefits* - bridges, partial dentures, full dentures | 50% of Delta Dental's allowed fee | 50% of Delta Dental's allowed fee | 50% of Delta Dental's allowed fee | Orthodontic benefits*- for adults and eligible dependent children | 50% of Delta Dental's allowed fee | 50% of Delta Dental's allowed fee | 50% of Delta Dental's allowed fee |
| TMJ benefit * | 50% of dentist's allowed fee (subject to a $500 lifetime maximum per person) | 50% of Delta Dental's allowed fee (subject to a $300 lifetime maximum per person) | 50% of Delta Dental's allowed fee (subject to a $250 lifetime maximum per person) |
| Implant benefit* | 50% of dentist's allowed fee (subject to a $1,000 lifetime maximum per person) | 50% of Delta Dental's allowed fee (subject to a $750 lifetime maximum per person) | 50% of Delta Dental's allowed fee (subject to a $500 lifetime maximum per person) |
| Crowns, jackets and other cast restorations* | 80% of dentist's allowed fee | 75% of Delta Dental's allowed fee | 70% of Delta Dental's allowed fee |
| When treatment is provided by | In-Network Delta Dental PPO Network | In-Network Delta Dental Premier Network | Out-of-Network Non-Delta Dental Dentists |
|---|---|---|---|
| Who's Covered | Employee and spouse as well as dependents to age 26. | Employee and spouse as well as dependents to age 26. | Employee and spouse as well as dependents to age 26. |
| Deductibles and Benefits Maximum | The maximum benefit paid per plan year is $500 per person. | The maximum benefit paid per plan year is $500 per person. | The maximum benefit paid per plan year is $500 per person. |
| Diagnostic and preventive benefits*-oral examinations, cleanings, x-rays, examinations of tissue biopsy, fluoride treatment, space maintainers, specialist consultations | 100% of dentist's allowed fee (no deductible applies for these services) | 100% of Delta Dental's allowed 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, sealants | N/A | N/A | N/A |
| Crowns, jackets and other cast restorations* | N/A | N/A | N/A |
| Prosthododontic benefits* - bridges, partial dentures, full dentures | N/A | N/A | N/A | Orthodontic benefits*- for adults and eligible dependent children | N/A | N/A | N/A |
| TMJ benefit * | N/A | N/A | N/A |
| Implant benefit* | N/A | N/A | N/A |
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