Delta Dental Benefit Highlights

Compare the benefit highlights of the Base Plan and the Enhanced Plan:

Base Plan

Benefits and Covered Services	Limitation	In-Network Dentist*	Out-Of-Network Dentist*
DIAGNOSTIC & PREVENTIVE BENEFITS
Oral examinations	Covered once in any six-month period.
Routine cleanings	Covered once in any six-month period.
X-rays	Covered once in any six-month period.	100%	100%
Fluoride treatment	Covered once in any six-month period.
Space Maintainers	Limited to age 14.
Sealants	Limited to age 19.
BASIC BENEFITS Fillings	Not covered.	0%	0%
MAJOR BENEFITS Crowns Inlays and onlays Cast restorations	Not covered. Not covered. Not covered.	0%	0%
ENDODONTICS Root canals	Not covered.	0%	0%
PERIODONTICS Gum treatment	Not covered.	0%	0%
ORAL SURGERY Incisions Excisions Surgical removal of tooth including simple extractions	Not covered. Not covered. Not covered.	0%	0%
PROSTHODONTICS Bridges Dentures	Not covered. Not covered.	0%	0%

^*Fees are based on PPO fees for In-PPO Network dentists and the MPA (maximum plan allowance) for Out-Of-PPO Network dentists. Reimbursement is paid on Delta Dental contract allowances and not necessarily each dentist's actual fees.

Who's Eligible:

• Primary enrollee, spouse or domestic partner, and eligible dependent children to age 19 or age 23 if a full-time student

Annual Maximum:

• The maximum benefit paid per calendar year is $1,000 per person in-PPO network
• The maximum benefit paid per calendar year is $1,000 per person out-of-PPO network

Rates Annually:

• Student Only - $144
• Student & Family - $499

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Enhanced Plan

Benefits and Covered Services*	Limitation	In-Network Dentist**	Out-Of-Network Dentist**
DIAGNOSTIC & PREVENTIVE BENEFITS
Oral examinations	Covered once in any six-month period.
Routine cleanings	Covered once in any six-month period.
X-rays	Covered once in any six-month period.	100%	100%
Fluoride treatment	Covered once in any six-month period.
Space Maintainers	Limited to age 14.
Sealants	Limited to age 19.
BASIC BENEFITS Fillings	Covered.	80%	80%
MAJOR BENEFITS Crowns Inlays and onlays Cast restorations	Not covered. Not covered. Not covered.	0%	0%
ENDODONTICS Root canals	Covered.	80%	80%
PERIODONTICS Gum treatment	Covered.	80%	80%
ORAL SURGERY Incisions Excisions Surgical removal of tooth including simple extractions	Covered. Covered. Covered.	80%	80%
PROSTHODONTICS Bridges Dentures	Not covered. Not covered.	0%	0%

^*Limitations or waiting periods may apply for some benefits; some services may be excluded. Please refer to your Evidence of Coverage or Summary Plan Description for waiting periods and a list of benefit limitations and exclusions.

^**Fees are based on PPO fees for In-PPO Network dentists and the MPA (maximum plan allowance) for Out-Of-PPO Network dentists. Reimbursement is paid on Delta Dental contract allowances and not necessarily each dentist's actual fees.

Who's Eligible:

• Primary enrollee, spouse or domestic partner, and eligible dependent children to age 19 or age 23 if a full-time student

Deductible:

• $50 per person per calendar year. Deductible does not apply to diagnostic and preventive services.

Annual Maximum:

• The maximum benefit paid per calendar year is $1,000 per person in-PPO network
• The maximum benefit paid per calendar year is $1,000 per person out-of-PPO network

Rates Annually:

• Student Only - $296
• Student & Family - $1027