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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.