Health Dental
  Dental Base Plan
Dental BUY-UP Plan
Delta Dental PPO
In-Network Dentist
Delta Dental Premier &
Out-of-Network Dentist
PPO In-Network
Dentist ONLY
Deductible$50/Individual
$150/Family
$50/Individual
$150/Family
Benefit Maximum
(calendar year)
Plan pays $2,000/IndividualPlan pays $3,000/Individual
Diagnostic and Preventive Benefits
(oral exams, cleanings, X-rays, etc.)*
No copay or deductibleDeductible appliesNo copay or deductible
Basic Benefits
(oral surgery, fillings, root canals, etc.)
You pay 20%You pay 20%
Crowns, Other Cast RestorationsYou pay 50%You pay 40%
Prosthodontic
(bridges, full and partial dentures)
You pay 50%You pay 40%
ImplantYou pay 50% with a $2,000 lifetime max/IndividualYou pay 40% with a $3,000 annual maximum/Individual
Orthodontic Benefits
(adults and children)
You pay 50% with a $2,000 lifetime max/IndividualYou pay 40% with a $3,000 lifetime maximum/Individual

* Not subject to benefit maximum.

Fees are based on Delta’s PPO fees for in-network dentists and the maximum plan allowance (MPA) for out-of-network dentists.