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Delta Dental Basic PPO Plan - Group #3365

Basics

Full-Time Employee * Contribution Per Pay Period

Employee Only: $0.00
Employee & Spouse/Partner: $0.00
Employee & Children: $0.00
Employee & Family: $0.00

Part-Time Employee * Contribution Per Pay Period

Employee Only $10.28
Employee & Spouse/Registered Domestic Partner $21.59
Employee & Child(ren) $18.51
Employee & Family $29.81

Lifetime maximum

Orthodontia is not covered

Plan Year

2023

Offered To

Employees

Body/Description

Delta Dental PPO is the dentist network for this plan.

This plan pays most benefits at a percentage.

Visit a PPO dentist to maximize your savings.

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

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

Non Network: Delta Dental Premier or non Delta Dental providers
- Preventive and diagnostic: 100% of Premier dentist fee or program allowance
- Basic procedures: 80% of Premier dentist fee or program allowance
- Major restorative procedures: 50% of Premier dentist fee or program allowance

You are responsible for amounts not covered by the dental plan.

Deductible

$50 per individual each calendar year
$150 per family each calendar year

Benefit Type

Dental

Annual maximum

$1,500 per individual

Cleanings

Preventive and diagnostic service:
100% (deductible waived)

Balance billing by a Non-Network dentist may apply. You are responsible for these charges.

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

Fluoride treatments

Preventive and diagnostic service:
100% (deductible waived)
Two per calendar year

Balance billing by your dentist may apply. You are responsible for these charges.

Routine exams

Preventive and diagnostic service:
100% (deductible waived)
Two per calendar year

Balance billing by your dentist may apply. You are responsible for these charges.

Sealants

Basic procedures service:
80% after deductible

X-rays

Preventive and diagnostic service:
100% (deductible waived)
Balance billing by your dentist may apply. You are responsible for these charges.

Orthodontia

Not covered

Retainers

80% with cost included in calendar year maximum; limited to cover replacements once in 5 years for mouthguards only.

Anesthesia

Basic procedures service:
80% after deductible

Bridges

Major Restorative procedures service:
50% after deductible

Crown

Major Restorative procedures service:
50% after deductible

Dentures

Major Restorative procedures service:
50% after deductible

Extractions

Basic procedures service:
80% after deductible

Fillings

Basic procedures service:
80% after deductible

Gingivectomy

Basic procedures service:
80% after deductible

Gold restorations

(Inlays & Onlays only)
Major Restorative procedures service:
50% after deductible

Implants

Not covered

Inlays

Major Restorative procedures service:
50% after deductible

Onlays

Major Restorative procedures service:
50% after deductible

Oral surgery

Basic procedures service:
80% after deductible

Periodontal surgery

Basic procedures service:
80% after deductible

Prescription drugs

Not covered

Root canals

Basic procedures service:
80% after deductible

Space maintainers

Preventive and diagnostic service:
100% (deductible waived)
Balance billing by your dentist may apply. You are responsible for these charges.

Splinting

Not covered

TMJ (Temporomandibular joint syndrome)

Not covered

X-rays

Preventive and diagnostic service:
100% (deductible waived)
Balance billing by your dentist may apply. You are responsible for these charges.