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% | |
Dental Guards (once every three years) |
You pay 50%, Plan pays $500 maximum/Person | You pay 50%, Plan pays $500 maximum/Person | |
Retainer Replacement (once every five years) |
You pay 50%, Plan pays $500 maximum/Person | You pay 50%, Plan pays $500 maximum/Person | |
Implants | 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.