Eligibility:
Primary enrollee, spouse and eligible dependent children to the end of the month the dependent turns 26.
Deductibles: $50 per person/$150 per family each calendar year. Deductible waived when seeing an in-network provider.
Maximums: $1,500 per person each calendar year. Diagnostic and Preventive services count towards this maximum.
Waiting Periods: There are no waiting periods.
Benefits and Covered Services:
| Benefits and Covered Services | Delta Dental PPO Dentists | Non-Delta Dental PPO Dentists |
|---|
| Diagnostic & Preventative Services (D & P) i.e. Exams, cleanings, x-rays | 100% | 100% |
| Basic Services i.e. Fillings and basic | 100% | 100% |
| Endodontics (root canals) | 100% | 100% |
| Periodontics (gum treatment) | 100% | 100% |
| Oral Surgery | 100% | 100% |
| Major Services i.e. Crowns, inlays, onlays, and cast restorations | 100% | 100% |
| Prosthodontics i.e. Bridges, dentures, and implants | 100% | 100% |
| Orthodontic Benefits - Adults and dependent children | 100% | 100% |
| Orthodontic Maximums | $1,000 Lifetime | $1,000 Lifetime |
| Accident Rider Benefits - Per person each calendar year | | |
- Limitations or waiting periods may apply for some benefits; some services may be excluded from your plan. Reimbursement is based on Delta Dental maximum contract allowances and not necessarily each dentist's submitted fees.
- Reimbursement is based on PPO contracted fees for PPO dentists, Delta Dental Premier contracted fees for Premier dentists and the program allowance for non-Delta Dental dentists.
