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Delta Dental Enhanced PPO Plan #3366 |
Delta Dental Basic PPO Plan #3365 |
| Basics | Show/Hide | |
Full-Time Employee * Contribution Per Pay Period |
Employee Only: $11.08 |
Employee Only: $0.00 |
Part-Time Employee * |
Employee Only: $19.99 |
Employee Only: $8.87 |
Overview |
This plan pays in-network benefits when your care is either provided or authorized by your Delta Dental PPO network dentist. If your network dentist does not provide or authorize your care, the charges are considered out-of-network. You are encouraged to obtain a predetermination of benefits from Delta for services greater than $300, or for crowns or bridges. |
Delta Dental PPO is the dentist network for this plan. This plan pays most benefits at a percentage. The benefit level does not depend on what providers you use. You are encouraged to obtain a predetermination of benefits from Delta for services greater than $300, or for crowns or bridges. |
Coinsurance |
Network: - Preventive and diagnostic: 100% of the negotiated rate - Basic procedures: 80% of the negotiated rate - Major restorative procedures: 50% of the negotiated rate Non-Network: - Preventive and diagnostic: 80% of usual & customary charges - Basic procedures: 60% of usual & customary charges - Major restorative procedures: 50% of usual & customary charges |
- Preventive and diagnostic: 100% of usual & customary charges - Basic procedures: 80% of usual & customary charges - Major restorative procedures: 50% of usual & customary charges You are responsible for amounts not covered by the dental plan. |
Deductible |
Network: $0 per individual/$0 per family Non-Network: $50 per individual/$150 family |
$50 per individual $150 per family |
Annual maximum |
Network: $3,000 per individual Non-Network: $1,500 per individual |
$1,000 per individual |
Lifetime maximum |
Orthodontia only: $1,500 | Orthodontia is not covered |
| Preventive Type of Care | Show/Hide | |
Cleanings |
Preventive and Diagnostic service: Plan allows up to three cleanings/year. The third cleaning applies to certain conditions including diabetics, pregnancy, those requiring periodontal maintenance and those in an active orthodontic treatment plan. |
Preventive and diagnostic service: Balance billing by a Non-Network dentist may apply. You are responsible for these charges. Plan allows up to three cleanings/year. The third cleaning applies to certain conditions including diabetics, pregnancy, and those requiring periodontal maintenance. |
Fluoride treatments |
Preventive and Diagnostic service: PPO or Premier Network Provider: 100% Non-Network: 80% (deductible waived) |
Preventive and diagnostic service: Balance billing by your dentist may apply. You are responsible for these charges. |
Routine exams |
Preventive and Diagnostic service: PPO or Premier Network Provider: 100% Non-Network: 80% (deductible waived) |
Preventive and diagnostic service: Balance billing by your dentist may apply. You are responsible for these charges. |
Sealants |
Basic procedures service: PPO Network Provider: 80% Premier or Non-Network Provider: 60% after deductible |
Basic procedures service: 80% after deductible |
X-rays |
Preventive and Diagnostic service: PPO or Premier Network Provider: 100% Non-Network: 80% (deductible waived) |
Preventive and diagnostic service: 100% (deductible waived) Balance billing by your dentist may apply. You are responsible for these charges. |
| Orthodontic Services | Show/Hide | |
Orthodontia |
Network: 50% of Delta's approved fee Combined Orthodontia lifetime maximum benefit of $1,500. Payment is split over two plan years at $750 per year and you must be enrolled in the Enhanced plan both years. |
Not covered |
Retainers |
(Covered under the Orthodontia benefit) PPO Network Provider: 50% of Delta's approved fee Premier or Non-Network: 50% of Delta's approved fee |
Not covered |
| Other Services (A-E) | Show/Hide | |
Anesthesia |
Basic procedures service: PPO Network Providers: 80% Premier or Non-Network: 60% after deductible |
Basic procedures service: 80% after deductible |
Bridges |
Major Restorative procedures service: PPO Network Providers: 50% Premier or Non-Network: 50% after deductible |
Major Restorative procedures service: 50% after deductible |
Crown |
Major Restorative procedures service: PPO Network Providers: 50% Premier or Non-Network: 50% after deductible |
Major Restorative procedures service: 50% after deductible |
Dentures |
Major Restorative procedures service: PPO Network Providers: 50% Premier or Non-Network: 50% after deductible |
Major Restorative procedures service: 50% after deductible |
Extractions |
Basic procedures service: PPO Network Providers: 80% Premier or Non-Network: 60% after deductible |
Basic procedures service: 80% after deductible |
| Other Services (F-O) | Show/Hide | |
Fillings |
Basic procedures service: PPO Network Providers: 80% Premier or Non-Network: 60% after deductible |
Basic procedures service: 80% after deductible |
Gingivectomy |
Basic procedures service: PPO Network Provider: 80% Premier or Non-Network: 60% after deductible |
Basic procedures service: 80% after deductible |
Gold restorations |
(Inlays & Onlays only) Major Restorative procedures service: PPO Network Provider: 50% Premier or Non-Network: 50% after deductible |
(Inlays & Onlays only) Major Restorative procedures service: 50% after deductible |
Implants |
Major Restorative procedures service: PPO Network Provider: 50% Premier or Non-Network: 50% after deductible |
Not covered |
Inlays |
Major Restorative procedures service: PPO Network Provider: 50% Premier or Non-Network: 50% after deductible |
Major Restorative procedures service: 50% after deductible |
Onlays |
Major Restorative procedures service: PPO Network Provider: 50% Premier or Non-Network: 50% after deductible |
Major Restorative procedures service: 50% after deductible |
Oral surgery |
Basic procedures service: PPO Network Provider: 80% Premier or Non-Network: 60% after deductible |
Basic procedures service: 80% after deductible |
| Other Services (P-Z) | Show/Hide | |
Periodontal surgery |
Basic procedures service: PPO Network Provider: 80% Premier or Non-Network: 60% after deductible |
Basic procedures service: 80% after deductible |
Prescription drugs |
Not covered | Not covered |
Root canals |
Basic procedures service: PPO Network Provider: 80% Premier or Non-Network: 60% after deductible |
Basic procedures service: 80% after deductible |
Space maintainers |
Preventive and Diagnostic service: PPO or Premier Network Provider: 100% Non-Network: 80% (deductible waived) |
Preventive and diagnostic service: 100% (deductible waived) Balance billing by your dentist may apply. You are responsible for these charges. |
Splinting |
Not covered | Not covered |
TMJ (Temporomandibular joint syndrome) |
Not covered | Not covered |