Alert
Delta Dental PPO plus Premier™
Group #4725
| Service | Low | Medium | High |
|---|---|---|---|
| Calendar year maximum (per person) | $750 | $1,250 | $2,000 |
| Calendar year deductible (waived on Preventive & Diagnostic) | |||
| Per person | $0 | $25 | $50 |
| Family aggregate | $0 | $75 | $150 |
| Preventive & Diagnostic | |||
| Exams, Cleanings (2 per calendar year) | 100% | 100% | 100% |
| Bitewing X-rays | 100% | 100% | 100% |
| Fluoride treatment (2 per calendar year to age 19) | 100% | 100% | 100% |
| Full mouth X-rays (1 per 5 years) | 100% | 100% | 100% |
| Basic Services (after deductible) | |||
| Fillings, extractions | 80% | 80% | 80% |
| Endodontics, Periodontal | 80% | 80% | 80% |
| Oral surgery | 80% | 80% | 80% |
| Crowns & Prosthodontics (after deductible) | |||
| Crowns, Inlays, Onlays, Bridgework | Not covered | 50% | 50% |
| Full and Partial Dentures | Not covered | 50% | 50% |
| Implants | |||
| Co-insurance | N/A | N/A | 50% |
| Lifetime maximum (per patient: Adult & Child, to age 26) | N/A | N/A | $3,500 |
| Orthodontics (Adult and Child) | |||
| Co-insurance | N/A | N/A | 50% |
| Lifetime maximum | N/A | N/A | $2,000 |
| Download | Download | Download |
Your dentist's network will impact how much you pay. Dentists that help participate in the Delta Dental PPO will have the lowest costs and will save you the most out of pocket expense. Dentists that participate in Delta Dental Premier, are participating Delta Dental dentists, but you will pay a greater portion of the cost if utilized. If you receive services from a non-participating, out of network dentists, you will pay the most out of pocket and are responsible for your coinsurance amount plus the difference between Delta Dental's approved fee and the dentist submitted fee for the claim.
