| Dental Plan Summary — Delta Dental
|
| |
| Services Covered |
Amount of Coverage |
| Calendar Year Maximum |
$1500 |
| Lifetime Orthodontic Maximum |
$1500 |
| Lifetime Maximum |
NA |
| Annual Deductible per member (applies to basic and major services) |
$50 |
| Diagnostic and Preventive Services |
100% |
| Oral Examinations |
Two in a twelve month period |
| Prophylaxis (cleanings) |
Two in a twelve month period |
| X-Rays |
|
|
Full mouth |
Once every 3 years
|
| Bite-wing
|
Two sets every 12 months
|
| Fluoride |
Under age 19 |
| Space Maintainers |
Under age 15 |
| Basic Services
[restorative (fillings), general anesthesia, occlusal guards, extractions and oral surgery* periodontics, endontics (root canal therapy)]
|
80% |
| Sealants |
Under age 16, one benefit per tooth. Chewing surfaces for permanent first and second molars only |
| Major Services |
50% |
|
Crowns
|
Porcelain, gold or veneer crowns for children under age 12 are not a benefit
|
| Bridges
|
Fixed bridges or cast partials for children under the age of 16 are not a benefit
|
| Partial Dentures / Full Dentures
|
|
| Orthodontics |
50% for dependents to age 24 |
| Reimbursements |
Freedom to choose either a participating dentist, or for a higher cost, a non-network dentist. In-network charges are paid based on Delta Dental's maximum fee schedule, which providers agree to accept, with no balance billing.
Out-of-network providers are generally reimbursed at the 51st percentile of Delta Dental's prevailing fee schedule as submitted by all providers (based on an overall scale of 100, the maximum payment is paid at or below the 51st percentile).
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This is a summary of dental care provisions. Every attempt has been made to assure accuracy.
