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2024 Delta Dental Enhanced PPO Plan #03366

Basics

Full-Time Employee * Contribution Per Pay Period

Employee Only $13.45
Employee & Spouse/Registered Domestic Partner $28.24
Employee & Child(ren) $24.21
Employee & Family $39.00

Part-Time Employee * Contribution Per Pay Period

Employee Only $24.00
Employee & Spouse/Registered Domestic Partner $50.39
Employee & Child(ren) $43.20
Employee & Family $69.59

Lifetime maximum

Orthodontia only: $1,500 per each covered member.

Plan Year

2024

Offered To

Employees

Body/Description

Delta Dental PPO is the dentist network for this plan. This plan pays in-network benefits when your care is either provided or authorized by your Delta Dental PPO network dentist.  Basic procedures by a Premier or non Delta Dental dentist will be covered at a lower percentage.

If your network dentist does not provide or authorize your care, the charges are considered out-of-network.

You are encouraged to obtain a predetermination of benefits from Delta for services greater than $300, or for crowns or bridges.

This document is a summary.  Please refer to the plan Evidence of Coverage (EOC) for more details.

Coinsurance

Network: Delta Dental PPO providers
- Preventive and diagnostic: 100% of the negotiated rate
- Basic procedures: 80% of the negotiated rate
- Major restorative procedures: 50% of the negotiated rate
Orthodontia 50% of the negotiated rate

Non-PPO Network: Delta Dental Premier or non Delta Dental providers
- Preventive and diagnostic: 100% of Premier dentist fee or 100% program allowance
- Basic procedures: 60% of Premier dentist fee or program allowance
- Major restorative procedures: 50% of Premier dentist fee or program allowance Orthodontia 50% of Premier dentist fee or program allowance
You are responsible for amounts not covered by the dental plan.

Deductible

Network: $0 per individual/$0 per family each calendar year
Non-PPO network: $50 per individual/$150 family each calendar year

Benefit Type

Dental

Annual maximum

Network: $3,000 per individual each calendar year

Non-PPO Network: $2,000 per individual each calendar year.
(Network and Non-PPO Network Maximum Combined for a total benefit of $2,000)

Diagnostic and Preventative services do not count towards annual maximum.

Cleanings

Preventive and Diagnostic service:
PPO or Premier Network Provider: 100%
Non-Network: 100% (deductible waived)

Plan allows up to three cleanings/year. The third cleaning applies to certain conditions including diabetics, pregnancy, those requiring periodontal maintenance and those in an active orthodontic treatment plan.

Fluoride treatments

Preventive and Diagnostic service:
PPO or Premier Network Provider: 100%
Non-Network: 100% (deductible waived)
Two per calendar year

Routine exams

Preventive and Diagnostic service:
PPO and Premier Network Provider: 100%
Non-Network: 100% (deductible waived)
Two per calendar year

Sealants

Basic procedures service for children to age 15:
PPO Network Provider: 80%
Premier or Non-Network: 60% after deductible

X-rays

Preventive and Diagnostic service:
PPO or Premier Network Provider: 100%
Non-Network: 100% (deductible waived)

Orthodontia

Network: 50% of Delta's approved fee
Non-PPO Network: 50% of Delta's approved fee
Orthodontia lifetime maximum benefit of $1,500 (combined). Payments are made in two installments: Once banding has occurred and 12 months later. You must be enrolled in the Enhanced plan throughout the entire treatment.

Retainers

(Covered under the Orthodontia benefit)
PPO Network Provider: 50% of Delta's approved fee
Premier or Non-Network: 50% of Delta's approved fee

Anesthesia

Basic procedures service:
PPO Network Providers: 80%
Premier or Non-Network: 60% after deductible

Bridges

Major Restorative procedures service:
PPO Network Providers: 50%
Premier or Non-Network: 50% after deductible

Crown

Major Restorative procedures service:
PPO Network Providers: 50%
Premier or Non-Network: 50% after deductible

Dentures

Major Restorative procedures service:
PPO Network Providers: 50%
Premier or Non-Network: 50% after deductible

Extractions

Basic procedures service:
PPO Network Providers: 80%
Premier or Non-Network: 60% after deductible

Fillings

Basic procedures service:
PPO Network Provider: 80%
Premier or Non-Network: 60% after deductible

Gingivectomy

Basic procedures service:
PPO Network Provider: 80%
Premier or Non-Network: 60% after deductible

Gold restorations

(Inlays & Onlays only)
Major Restorative procedures service:
PPO Network Provider: 50%
Premier or Non-Network: 50% after deductible

Implants

Major Restorative procedures service:
PPO Network Provider: 50%
Premier or Non-Network: 50% after deductible

Inlays

Major Restorative procedures service:
PPO Network Provider: 50%
Premier or Non-Network: 50% after deductible

Onlays

Major Restorative procedures service:
PPO Network Provider: 50%
Premier or Non-Network: 50% after deductible

Oral surgery

Basic procedures service:
PPO Network Provider: 80%
Premier or Non-Network: 60% after deductible

Periodontal surgery

Basic procedures service:
PPO Network Provider: 80%
Premier or Non-Network: 60% after deductible

Prescription drugs

Not covered

Root canals

Basic procedures service:
PPO Network Provider: 80%
Premier or Non-Network: 60% after deductible

Space maintainers

Preventive and Diagnostic service:
PPO or Premier Network Provider: 100%
Non-Network: 100% (deductible waived)

Splinting

Not covered

TMJ (Temporomandibular joint syndrome)

Not covered

X-rays

Preventive and Diagnostic service:
PPO or Premier Network Provider: 100%
Non-Network: 100% (deductible waived)