Delta Dental PPO plus Premier™ - Basic
Group #4616
| Service | Delta Dental PPO Plus Premier™ Basic plan |
|---|---|
| Calendar year maximum (per person) | $1,000 |
| Calendar year deductible (waived on Preventive & Diagnostic) | |
| Per person | $50 |
| Family aggregate | $100 |
| Preventive & Diagnostic | |
| Exams, Cleanings, Bitewing X-Rays (2 per calendar year) | 100% |
| Fluoride treatment (2 per calendar year for children to age 19) | 100% |
| Sealants (to age 16) | 100% |
| Basic Services (after deductible) | |
| Extractions, Root canals (Endodontics) | 80% |
| Periodontal, Oral surgery | 80% |
| Repair of dentures | 80% |
| Fillings - Composite/Resin (anterior & posterior teeth) | 80% |
| Crowns & Prosthodontics (after deductible) | |
| Crowns, gold restorations (payable every 8 years) | Not a benefit |
| Bridgework, full and partial dentures (payable every 8 years) | Not a benefit |
| Implants | Not a benefit |
| Orthodontics (Adult and Dependent Children) | |
| Co-insurance | Not a benefit |
| Lifetime maximum (per person) | N/A |
| TMJ | |
| Co-insurance | Not a benefit |
| Lifetime maximum (per person) | N/A |
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Delta Dental’s Oral Health Enhancement Option enables you to receive up to four dental cleanings and/or periodontal maintenance procedures in any combination per benefit period if you have been treated for periodontal (gum) disease in the past. For the additional dental cleanings and/or periodontal maintenance procedures to be covered, you must have had periodontal surgery or periodontal scaling and planing in the past. Details on how to qualify can be found in your benefit booklet.
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.
Delta Dental of Connecticut is a part of Delta Dental Plans Association. Through our national network of Delta Dental companies, we offer dental coverage in all 50 states, Puerto Rico and other U.S. territories.
