NJM Plan comparison
Group #03665-06001
| Service | Delta Dental PPO™ Benefit | Delta Dental PPO Plus Premier™ Benefit |
|---|---|---|
| Calendar year maximum (per person) | $2,000 | $1,500 |
| Calendar year deductible (waived on Preventive & Diagnostic) | ||
| Per person | $25 | $50 |
| Family aggregate | $75 | $150 |
| Preventive & diagnostic | ||
| Exams, cleanings (each twice in a calendar year) | 100% | 100% |
| Bitewing x‐rays (twice per calendar year for persons 18 and younger, once per calendar year for persons age 19 and over) | 100% | 100% |
| Fluoride treatment (once in a calendar year, children to age 19) | 100% | 100% |
| Remaining Basic services | ||
| Fillings (including composite restorations on back teeth), Extractions | 80% | 80% |
| Endodontics (root canal) | 80% | 80% |
| General periodontics | 80% | 80% |
| Oral surgery | 80% | 80% |
| Sealants | 80% | 80% |
| Crowns & Prosthodontics | ||
| Crowns, gold restorations (over natural teeth) | 50% | 50% |
| Bridgework | 50% | 50% |
| Full & partial dentures | 50% | 50% |
| Implants | 50% | 50% |
| Major Services | ||
| Crowns, gold restorations (over natural teeth – once per tooth per five years) | 50% | 50% |
| Bridgework | 50% | 50% |
| Full and partial denture | 50% | 50% |
| Orthodontics (Child & Adult) | ||
| Full comprehensive treatment | 50% | 50% |
| Lifetime maximum (per patient) | $2,000 | $1,000 |
Your dentist's network will impact how much you pay. Dentists that participate in 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 dentist, 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.
