Delta Dental Plan Benefit Summary
The plan pays the same benefit level for covered dental charges regardless of the provider you use. Your out-of pocket cost may be less when you use network dentists because they agree to charge negotiated fees. Non-network dentists, on the other hand, have not agreed to negotiated rates, so your share of the charges will generally be greater when you receive care outside the network.
| DENTAL PLAN AT-A-GLANCE |
| Plan Provision |
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| Choice of Provider |
The provider of your choice |
| Annual Deductible |
$100 per person/$300 per family |
| Annual Maximum Benefit |
$2,000 per person
Preventive, diagnostic, and orthodontic care do not count toward your annual maximum benefit, so your benefit goes farther |
| Covered Services |
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Preventive & Diagnostic Care:
-Routine exams (two per year)
-Cleanings (three per year)
-Fluoride application for children to age 19 (two per year)
-Bitewing x-rays (one per year for adults, two per year for children to age 19)
-Sealants for children to age 19 (one every three years)
Additional Benefits during pregnancy: The plan will pay for additional services to help improve oral health during pregnancy. The additional services each calendar year include: one additional oral examination and either one additional routine cleaning or one additional periodontal scaling and root planing per quadrant. You or your dentist must provide written confirmation of your pregnancy when the claim is submitted.
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Network: 100% (deductible waived)
Non-network: 100% of UCR (deductible waived)
Preventive and diagnostic care do not count toward your annual maximum benefit
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| Basic Restorative Care: fillings, one complete x-ray series every 12 months, simple extractions and oral surgery, root canal therapy, general anesthesia, periodontics (except surgery), and endodontics. |
Network: 80% after deductible
Non-network: 80% of UCR after deductible |
| Major Restorative Care: crowns, dentures, bridges, dental implants, inlays, onlays, periodontal surgery, complex oral surgery, and surgery for impacted teeth. Replacement for bridges, crowns, and dentures once every seven years. |
Network: 50% after deductible
Non-network: 50% of UCR after deductible |
Orthodontic Care for Children and Adults: diagnostic procedures (x-rays, casts and treatment plan), appliance therapy and active treatment per month after the first month.
Orthodontic care does not count toward your annual maximum benefit |
Network: 50% (deductible waived)
Non-network: 50% of UCR (deductible waived)
$2,000 lifetime maximum benefit |