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
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
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.
- 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
$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.
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.
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.
100% (deductible waived)
Two per calendar year
Balance billing by your dentist may apply. You are responsible for these charges.
Sealants
Basic procedures service for children to age 15:
80% after deductible
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.
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
80% after deductible
Bridges
Major Restorative procedures service:
50% after deductible
50% after deductible
Crown
Major Restorative procedures service:
50% after deductible
50% after deductible
Dentures
Major Restorative procedures service:
50% after deductible
50% after deductible
Extractions
Basic procedures service:
80% after deductible
80% after deductible
Fillings
Basic procedures service:
80% after deductible
80% after deductible
Gingivectomy
Basic procedures service:
80% after deductible
80% after deductible
Gold restorations
(Inlays & Onlays only)
Major Restorative procedures service:
50% after deductible
Major Restorative procedures service:
50% after deductible
Implants
Not covered
Inlays
Major Restorative procedures service:
50% after deductible
50% after deductible
Onlays
Major Restorative procedures service:
50% after deductible
50% after deductible
Oral surgery
Basic procedures service:
80% after deductible
80% after deductible
Periodontal surgery
Basic procedures service:
80% after deductible
80% after deductible
Prescription drugs
Not covered
Root canals
Basic procedures service:
80% after deductible
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.
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.
100% (deductible waived)
Balance billing by your dentist may apply. You are responsible for these charges.