27
Dental
Under the Delta Dental Preferred Provider Organization (PPO) plan, dental services are provided
through the Delta Dental PPO network. However, you can visit dentists inside or outside the
network. What you pay depends on whether you choose a participating dentist. If you choose
a non-participating dentist, you pay the difference between the amount the dentist receives
from Delta Dental (the “allowable amount”) and the dentist’s charges.
You may also choose to visit a Delta Dental
Premier
provider. Premier dentists may not bill above
Delta Dental’s allowable amount, so your out-of-pocket costs may be lower than with a non-
participating dentist. Your costs are usually lowest when you visit a Delta Dental PPO dentist.
Pre-authorization from Delta Dental is recommended for charges of $250 or more.
SEA/Confidential, SEIU, SMA, PSMA, Unrepresented Management, Department Directors
Dental Benefits
Delta Dental PPO Core
Delta Dental PPO Buy up
In-Network
Out-of-Network*
In-Network
Out-Of-Network*
Calendar Year Deductible
$50 indiv / $150 family
None
$50 indiv /$150 family
Annual Plan Maximum
$1,100
$1,000
$1,600
$1,500
Diagnostic & Preventive
Plan pays 100%
Plan pays 100%
Plan pays 100%
Plan pays 100%
Basic Services
Fillings
Plan pays 80%
Plan pays 80%
Plan pays 80%
Plan pays 80%
Root Canals
Plan pays 80%
Plan pays 80%
Plan pays 80%
Plan pays 80%
Periodontics
Plan pays 80%
Plan pays 80%
Plan pays 80%
Plan pays 80%
Major Services
Plan pays 75%
Plan pays 75%
Plan pays 75%
Plan pays 75%
Orthodontic Services
Orthodontia**
Plan pays 50%
Plan pays 50%
Plan pays 50%
Plan pays 50%
Lifetime Maximum
$1,000
$1,000
$1,500
$1,500
Dependent Children
Covered to age 23
Covered to age 23
Covered to age 23
Covered to age 23
*Non-Delta Dentists are reimbursed at the lesser of the submitted charge or the fee that satisfies the majority of dentists in the same
geographical area with the same training (51st percentile of Usual, Customary and Reasonable)
**Orthodontic benefit can be prorated based on number of treatment months. Please see HR for more information.