NJM PPO Plan Benefits Overview
Group #03665-06001
| Service | Delta Dental PPO™ Benefit |
|---|---|
| Calendar year maximum (per person) | $2,000 |
| Calendar year deductible (waived on Preventive & Diagnostic) | |
| Per person | $25 |
| Family aggregate | $75 |
| Preventive & diagnostic | |
| Exams, cleanings (each twice in a calendar year) | 100% |
| Bitewing x‐rays (twice per calendar year for persons 18 and younger, once per calendar year for persons age 19 and over) | 100% |
| Fluoride treatment (once in a calendar year, children to age 19) | 100% |
| Remaining Basic services | |
| Fillings (including composite restorations on back teeth), Extractions | 80% |
| Endodontics (root canal) | 80% |
| General periodontics | 80% |
| Oral surgery | 80% |
| Sealants | 80% |
| Crowns & Prosthodontics | |
| Crowns, gold restorations (over natural teeth) | 50% |
| Bridgework | 50% |
| Full & partial dentures | 50% |
| Implants | 50% |
| Major services | |
| Crowns, gold restorations (over natural teeth – once per tooth per five years) | 50% |
| Bridgework | 50% |
| Full and partial denture | 50% |
| Orthodontics (Child & Adult) | |
| Full comprehensive treatment | 50% |
| Lifetime maximum (per patient) | $2,000 |
This program is based upon a network of Delta Dental PPO dental offices, although you may choose any fully licensed dentist to render necessary services. Participating dentists will be paid directly by Delta Dental to the extent that services are covered by the contract. Non-participating dentists will bill the patient directly, and Delta Dental will make payment directly to the subscriber. Patients who select a non-Delta Dental PPO dentist have benefits paid on a Delta Dental PPO schedule of allowances and are responsible for any part of the dentist's fee which exceeds the allowance except that a Delta Dental participating dentist can only charge up to his/her filed fee or Delta Dental's maximum plan allowance, whichever is less. Maximum benefit may be derived by utilizing the services of a participating Delta Dental PPO dentist.
