Download DENTAL (Delta Dental) This chart shows what you pay when you

DENTAL (Delta Dental)
This chart shows what you pay when you use services.
Network
Deductible
Preventive
Services 3
Basic/Minor
Services
Major
Services
Preventive
Option
PPO or
Premier
Providers 2
None
Buy Up Option 1
Basic Option
PPO or
Premier
Providers 2
$50/individual
$150/family4
Out of
network
Providers 2
$50/individual
$150/family4
PPO or
Premier
Providers 2
$50/individual
$150/family4
Out of
network
Providers 2
$50/individual
$150/family4
Deductible does not apply. You pay $0/0% of NNR 2
Not covered
Not covered
Deductible
then 20%
NNR 3
Deductible
then 50% NNR
Deductible
then 40% NNR
Deductible
then 20% NNR
Deductible
then 20% NNR
3
3
3
Deductible
then 60% NNR
Deductible
then 50% NNR
Deductible
then 50% NNR
3
3
3
3
Maximum
Annual
Benefit
Payable
Amount over
Amount over
Amount over
Amount over annual plan
annual plan
annual plan
annual plan
maximum of $2,000 per person
maximum of
maximum of
maximum of
$1,000 per
$1,500 per
$1,000 per
person
person
person
5
Orthodontia
Not covered
Not covered
50% NNR 5
Lifetime Ortho Not covered
Not covered
Amount over lifetime plan
Benefit
maximum $2,000
Payable
1
Must remain enrolled in this option for 2 enrollment cycles
2
In network and out of network benefit calculated at Delta Dental Premier network negotiated rates (NNR).
Out of network providers may bill you for any difference between their billed charge and the NNR.
3
Preventive services include: exams, cleanings and fluoride (once per calendar year limited to those under
age 19). Deductible does not apply to Preventive services or Orthodontia. Deductible applies to Basic/Minor
and Major Services. After the deductible, you pay the percentage shown.
4
Three or more family members’ expenses can be combined to meet the family deductible.
5
Orthodontia only covered for covered children under age 19.
Definitions:
Preventive services include: oral exams, cleanings (twice per calendar year), x-rays (once per calendar year
with full mouth x-rays once in any five year period) and fluoride (once per calendar year limited to those
under age 19). If you have a specific at-risk health condition you may be eligible for additional cleanings or
fluoride treatment. Talk to your dentist about this treatment.
Basic/Minor services include: fillings; crown repairs; root canals, periodontic services to treat gum disease;
extractions and dental surgery; denture repairs for partial or full dentures.
Major services include: crowns; bridge repairs; implant maintenance, repair and removal; denture relines
and rebase; denture adjustments; bridges and dentures.