Retiree voluntary benefits - Delta Dental PPO Plus Premier™
| Plan highlights | |||
|---|---|---|---|
| Lifetime deductible – $100 (once per lifetime as long as policy is in force – does not apply to preventive and diagnostic) | |||
| Waiting period – None, coverage begins as of the coverage effective date if you enroll when initially eligible | |||
| Calendar year maximum | Premium plan $2,000 |
Standard plan $1,500 |
Basic plan $1,000 |
Delta Dental PPO Plus Premier™ benefits*
| Preventive & diagnostic | Premium plan | Standard plan | Basic plan |
|---|---|---|---|
| Dental evaluations | 100% | 100% | 100% |
| Routine cleanings | 100% | 100% | 100% |
| Bitewing X-rays | 100% | 100% | 100% |
| Full-mouth X-rays (a series of individual X-rays or a panoramic X-ray) | 100% | 100% | 100% |
| Fluoride | 100% | 100% | 100% |
| Sealants on the decay-free, biting surface of permanent molars | 100% | 100% | 100% |
| Space maintainers when a primary molar tooth is prematurely lost | 100% | 100% | 100% |
| Emergency treatment to relieve pain | 100% | 100% | 100% |
| Basic services | Premium plan | Standard plan | Basic plan |
| Composite (tooth colored) fillings or Amalgam (silver) fillings on any teeth | 80% | 80% | 50% |
| Non-surgical extractions | 50% | 50% | 50% |
| Major services | Premium plan | Standard plan | Basic plan |
| Crowns – Repair of teeth with crowns when they cannot be restored with other filling materials | 50% | 50% | 50% |
| Endodontics – The care of teeth with damaged nerves, such as root canal treatment | 50% | 50% | 50% |
| Periodontics – The treatment of diseases of the gums and supporting bone, such as scaling and root planing | 50% | 50% | 50% |
| Oral surgery – Surgical extractions and other dental surgery | 50% | 50% | 50% |
| Fixed and removable prosthodontics – Dental services and appliances to replace missing teeth, such as dentures and bridges (excluding implants), including repairs | 50% | 50% | 50% |
| Implants – Dental services for surgical placement of implant body and implant abutment supported crowns | 50% | 50% | 50% |
| Adjunctive general services – Dental services include general anesthesia, and palliative care (temporary treatment of dental pain) | 50% | 50% | 50% |
| Additional services | Premium plan | Standard plan | Basic plan |
| Oral Health Enhancement - 2 additional cleanings per year for members with a history of periodontal disease | 
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| Integrative Care - 2 additional cleanings per year for members with certain chronic health conditions |
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Enrollment and eligibility rules apply
Enrollment
Retired employees may enroll in this plan during the initial open enrollment period offered to eligible retirees as defined by your former employer.
Thereafter, employees who retire may enroll and select any of the three retiree plans upon the date of retirement or within (90) days of retirement. Benefits will be effective the first of the month following the date of enrollment.
If you are a retiree enrolled in COBRA or another qualifying dental plan prior to enrolling in the retiree plan
You will have the option to enroll within 90 days in any of the three retiree dental plans upon termination of COBRA or qualifying dental plan. Benefits will be effective the first of the month following the date of enrollment upon validation of prior coverage.
If you do enroll as a late entrant:
If you don’t enroll upon initial eligibility as a retiree or within the 90-day period following the date of your retirement, upon termination of COBRA or another qualifying dental plan, you may enroll as a late entrant. A 12-month waiting period will apply to major services for the Premium and Standard plans. No waiting period will apply to the Basic plan. Your benefits will be effective on the first of the month on following the date of enrollment.
