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Dental – Delta Dental, continued
Dental Base with Orthodontic Benefit Plan
Calendar Year Deductibles
$25 per person
$50 per family
Calendar Year
Plan
Maximums
PPO Dentists: $2,100
Non-PPO Dentists: $2,000
Waiting Period
Basic Benefits
None
Major Benefits
None
Prosthodontics
12 months
Orthodontics
None
Benefits and Covered
Services
Delta Dental¹
PPO Dentists
Non-PPO²
Dentists
Diagnostic and Preventive
(D&P)
Exams, cleanings and x-rays
100%
100%
Basic Services
Fillings, simple tooth
extractions, sealants and night
guards
80%
80%
Endodontics
(root canals)
Covered under basic services
80%
80%
Periodontics
(gum treatment)
Covered under basic services
80%
80%
Oral Surgery
Covered under basic services
80%
80%
Major Services
Crowns, inlays, onlays and cast
restorations
50%
50%
Prosthodontics
Bridges, dentures and implants
50%
50%
Orthodontic Benefits
Adults and Dependent Children
50%
50%
Orthodontic Maximum
$3,000 Lifetime
$3,000 Lifetime
¹Limitations or waiting periods may apply for some benefits, some services may be excluded from your plan. Reimbursement is based on
Delta Dental maximum contract allowances and not necessarily each dentist’s submitted fees.
²Reimbursement is based on PPO contracted fees for PPO dentists, Premier contracted fees for Premier dentists and program allowance for
non-Delta Dental dentists.