| 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/Individual | Plan pays $3,000/Individual | |
| Diagnostic and Preventive Benefits (oral exams, cleanings, X-rays, etc.)* |
No copay or deductible | Deductible applies | No copay or deductible |
| Basic Benefits (oral surgery, fillings, root canals, etc.) |
You pay 20% | You pay 20% | |
| Crowns, Other Cast Restorations | You pay 50% | You pay 40% | |
| Prosthodontic (bridges, full and partial dentures) |
You pay 50% | You pay 40% | |
| Implant | You pay 50% with a $2,000 lifetime max/Individual | You pay 40% with a $3,000 annual maximum/Individual | |
| Orthodontic Benefits (adults and children) |
You pay 50% with a $2,000 lifetime max/Individual | You 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.