Dental Plan Options
Delta Dental is offered through two networks—Delta Dental PPO and Delta Dental Premier®. You can go to any licensed dentist regardless of whether your dentist participates in the Delta Dental network. However, you will receive the most value and maximize your savings by choosing a dentist in the Delta Dental PPO network. The benefits under each option are summarized below.
Dental Benefits are not available to retired participants.
| Benefits |
Delta Dental PPO Dentists** |
Delta Dental Premier Dentists** |
Non-Delta Dental Dentists** |
|
Deductibles Per member each calendar year |
No Deductible | No Deductible | No Deductible |
|
Maximums (includes all covered services including Diagnostic and Preventive services) Per member each calendar year |
$1,750 | $1,750 | $1,750 |
| Covered Services * | Delta Dental PPO Dentists** | Delta Dental Premier Dentists** | Non-Delta Dental Dentists** |
| Diagnostic & Preventive Services (D&P) Exams, Cleanings and X-Rays | 100% | 100% | 100% |
| Basic Services | 85% | 75% | 50% |
| Covered Services * | Delta Dental PPO Dentists** | Delta Dental Premier Dentists** | Non-Delta Dental Dentists** |
| Fillings, Sealants, Space Maintainers, Simple Extractions and Posterior Composites | |||
| Endodontics Root Canals |
85% | 75% | 50% |
|
Periodontics Surgical and Non-Surgical Periodontics |
85% | 75% | 50% |
| Oral Surgery | 85% | 75% | 50% |
|
Major Services Crowns, Inlays, Onlays and Cast Restorations |
80% | 70% | 50% |
|
Prosthodontics Bridges, Dentures and Denture Repair/Reline/Rebase |
80% | 70% | 50% |
| Temporomandibular Joint (TMJ) Services | 85% | 75% | 50% |
| TMJ Lifetime Maximum | $2,000 | $2,000 | $2,000 |
| Orthodontic Services Dependent Children |
50% | 50% | 50% |
| Orthodontic Lifetime Maximum | $1,500 | $1,500 | $1,500 |
* Limitations 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.
** The coinsurance shown here reflects your cost-sharing responsibility. Reimbursement is based on PPO contracted fees for PPO dentists, Premier contracted fees for Premier dentists and program allowance for non-Delta Dental dentists.
Delta Dental Network
The Delta Dental network allows you to maximize your benefits and pay less out of pocket by seeing a Delta Dental PPO dentist. These dentists have agreed to reduced fees, and you won’t get charged more than your expected share of the bill. If you can’t find a PPO dentist, your next best option is to go to a Delta Dental Premier® dentist. These dentists have agreed to set fees and offer another opportunity to save. Your out-of-pocket costs will be higher if you choose an out-of-network (non-Delta Dental) dentist because they can balance bill you for the difference between their submitted fees and the Allowed Amount.
