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Dental
Delta Dental PPO (SISC)
CSEA and Unrepresented
In-Network
Premier & Out-Of-Network
Calendar Year Deductible
Individual/Family
None
None
Annual Plan Maximum
$2,500
$2,400
Diagnostic and Preventive
Oral Exam
X-rays
Teeth Cleaning
Fluoride Treatment
Sealants
Plan pays 100%
Plan pays 100%
Basic Services
Anesthesia
Periodontics (gum disease)
Endodontics (root canal)
Simple & surgical
extractions
Plan pays 70-100%
Plan pays 70-100%
Major Services
Single crowns
Inlays, onlays, veneers
Plan pays 70-100%
Plan pays 70-100%
Prosthodontic Services
Bridges & dentures
Repair & maintenance of
bridgework
Dental Implants (
extensive
)
Plan pays 70-100%
Plan pays 70-100%
Orthodontic Services
Orthodontia (
Adult & Child
)
Plan pays 75%
$3,000
Lifetime Maximum
The information in this booklet is a general outline of the benefits offered under College of Marin benefits program. This booklet may not include all relevant limitations and conditions.
Specific details and limitations are provided in the plan documents, which may include a Summary of Plan Description (SPD), Evidence of Coverage (EOC), and/or insurance policies. The
plan documents contain relevant plan provisions. If the information in this booklet differs from the plan documents, the plan documents will prevail.