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Comparison of Delta Dental Premier (Enhanced) and Delta Dental PPO

Coverage under Delta Dental (Enhanced) Premier Delta Dental PPO
Excluded Employees (1) In-Network Delta Dental PPO dentists (2) Out-of-Network (non- Delta Dental PPO dentists)
Who's covered? (primary enrollee, spouse and eligible children) Employees and Dependents Employees, Retirees and Dependents Employees, Retirees and Dependents
Deductible (per person annually) $25 $25 $75
Family Deductible (annually) $100 $100 $200
Maximum (per person annually) $2,000 $2,000 $1,000
Diagnostic and Preventive (no deductive) 100% of Delta Dental dentist's fees 100% of Delta Dental PPO approved fees 80% of Delta Dental PPO approved fee (3)
Basic Benefits: (extractions, root canals, periodontic treatment, sealants) 90% of Delta Dental dentist's fee 90% of Delta Dental PPO approved fee 80% of Delta Dental PPO approved fee
Crowns and cast restorations 80% of Delta Dental dentist's fee 80% of Delta Dental PPO approved fee 50% of Delta Dental PPO approved fee
Prosthodontic bridges, dentures 50% of Delta Dental dentist's fee 60% of Delta Dental PPO approved fee 50% of Delta Dental PPO approved fee
Orthodontic 50% of Delta Dental dentist's fee 50% of Delta Dental PPO approved fee 50% of Delta Dental PPO approved fee
Orthodontic Maximum $1,000 lifetime maximum

$1,000 lifetime maximum per adult

$1,500 per child

$1,000 lifetime maximum per adult

$1,000 per child

Implant Benefits Not covered

50% of Delta Dental PPO approved fee

$2,500 lifetime maximum

50% of Delta Dental PPO approved fee

$2,500 lifetime maximum

Other Coverage Third cleaning per year for high-risk patients (4) Third cleaning per year for high-risk patients (4)

Notes:

(1) Managerial, supervisory, confidential and all other employees excluded from collective bargaining.

(2)* In California, Delta Dental endodontists, oral surgeons and periodontists are not Delta Dental PPO dentists, but you receive in-network benefits when visiting one of these specialists. You must visit a Delta Dental PPO prosthodontist or Delta Dental PPO orthodontist to receive the maximum in-network benefits under the program.

(3) When visiting a non-Delta Dental PPO dentist, you pay the difference between the dentist's fee and the Delta Dental-approved fee plus the copayment.

(4) High-risk patients are defined as patients with compromising systemic diseases or medical conditions such as, but not limited to:

  • Diabetes, AIDS, organ transplant, endocarditis
  • Pregnant women
  • Cancer chemotherapy patients

(5) For employees in Consolidated Benefits (CoBen), the monthly out-of-pocket premium may vary depending on their other CoBen elections.


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