DSV Delta Dental PPO plus Premier™ - Buy-up plan 1
Group #09703
| In-network | Out-of-network | ||
|---|---|---|---|
| Buy-up Plan 1 |
If a Delta Dental PPOTM or |
If a Non-Participating Dentist is used |
|
| Preventive & Diagnostic Services | |||
| Exams (2x per Plan Year), Cleanings (2x per Plan Year, 4x if in Active Periodontal Therapy; Cleanings combined with Periodontal Maintenance), | 100% |
100% | |
| Bitewing X-Rays, Full Mouth X-Rays, Periapical X-Rays, Intraoral X-Rays, | 100% |
100% | |
| Specialty Consultations, Flouride Treatments, | 100% |
100% | |
| Sealants, Space Maintainers | 100% |
100% | |
| Basic Services | |||
| Fillings (Composite Fillings on all teeth), | 80% |
80% | |
| Simple Extractions, Root Canals (Endodontics), | 80% |
80% | |
| Oral Surgery Excluding Impacted Extractions, Non-Surgical Periodontics, | 80% |
80% | |
| Denture Repair, Occlusal Guards, | 80% |
80% | |
| Prefabricated Stainless Steel & Resin Crowns | 80% |
80% | |
| Major Services | |
||
| Non-Prefabricated Crowns & Gold Restorations, | 50% | 50% | |
| Bridgework, Full & Partial Dentures, | 50% | 50% | |
| Implants, Prosthesis over Implant, Impacted Extractions, | 50% | 50% | |
| Surgical Periodontics | 50% | 50% | |
|
Plan Year Maximum (per person) |
$1,500 | $1,500 | |
|
Plan Deductible |
|
||
| Per Person | $50 | $50 | |
| Family Maximum | $150 | $150 | |
| Waived for | Preventive & Diagnostic | Preventive & Diagnostic | |
| Download | |||
Your dentist's network will impact how much you pay. Dentists that help participate in the Delta Dental PPO will have the lowest costs and will save you the most out of pocket expense. Dentists that participate in Delta Dental Premier, are participating Delta Dental dentists, but you will pay a greater portion of the cost if utilized. If you receive services from a non-participating, out of network dentists, you will pay the most out of pocket and are responsible for your coinsurance amount plus the difference between Delta Dental's approved fee and the dentist submitted fee for the claim.
