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Delta Dental PPO Plan #1149 |
| BasicsShow/Hide | |
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. |
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: - All services: 50% of usual & customary charges |
Deductible |
Network: $0 per individual/$0 per family Non-network: $50 per individual/$150 family |
Annual maximum |
Network & Non-Network Combined: $1,000 per individual |
| Other Services (A-E)Show/Hide | |
Anesthesia |
Basic procedures service: Network: 80% Non-Network: 50% after deductible |
Bridges |
Major Restorative procedures service: Network: 50% Non-Network: 50% after deductible |
Crown |
Major Restorative procedures service: Network: 50% Non-Network: 50% after deductible |
Dentures |
Major Restorative procedures service: Network: 50% Non-Network: 50% after deductible |
Extractions |
Basic procedures service: Network: 80% Non-Network: 50% after deductible |
| Other Services (F-O)Show/Hide | |
Fillings |
Basic procedures service: Network: 80% Non-Network: 50% after deductible |
Gingivectomy |
Basic procedures service: Network: 80% Non-Network: 50% after deductible |
Gold restorations |
(Inlays & Onlays only) Major Restorative procedures service: Network: 50% Non-Network: 50% after deductible |
Inlays |
Major Restorative procedures service: Network: 50% Non-Network: 50% after deductible |
Implants |
Major Restorative procedures service: Network: 50% Non-Network: 50% after deductible |
Onlays |
Major Restorative procedures service: Network: 50% Non-Network: 50% after deductible |
Oral surgery |
Basic procedures service: Network: 80% Non-Network: 50% after deductible |
| Other Services (P-Z)Show/Hide | |
Periodontal surgery |
Basic procedures service: Network: 80% Non-Network: 50% after deductible |
Prescription drugs |
Not covered |
Root canals |
Basic procedures service: Network: 80% Non-Network: 50% after deductible |
Space maintainers |
Preventive and Diagnostic service: Network: 100% Non-Network: 50% (deductible waived) |
Splinting |
Not covered |
TMJ (Temporomandibular joint syndrome) |
Not covered |
| Preventive Type of CareShow/Hide | |
Cleanings |
Preventive and Diagnostic service: Network: 100% Non-Network: 50% (deductible waived) Plan allows up to 2 cleanings a year. |
Fluoride treatments |
Preventive and Diagnostic service: Network: 100% Non-Network: 50% (deductible waived) |
Routine exams |
Preventive and Diagnostic service: Network: 100% Non-Network: 50% (deductible waived) |
Sealants |
Basic procedures service: Network: 80% Non-Network: 50% after deductible |
X-rays |
Preventive and Diagnostic service: Network: 100% Non-Network: 50% (deductible waived) |