Notice
Change Healthcare announced a breach of HIPAA privacy and is reaching out to individuals whose personal information may have been compromised. Although this incident does not involve Delta Dental of New Jersey or Connecticut, Change Healthcare is a vendor we used and we are providing this information to help our members who might be affected.
NJM PPO Plus Premier Benefits Overview
Group #03665-06001
| Service | Delta Dental PPO Plus Premier™ Benefit |
|---|---|
| Calendar year maximum (per person) | $1,500 |
| Calendar year deductible (waived on Preventive & Diagnostic) | |
| Per person | $50 |
| Family aggregate | $150 |
| 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) | $1,000 |
Where the eligible patient is treated by a Delta Dental PPOTM dentist, the fee for the covered service(s) will not exceed the Delta Dental PPO maximum allowable charge(s). Where the eligible patient is treated by a Delta Dental Premier® dentist who does not participate in Delta Dental PPO or by a Participating Specialist, the dentist has agreed not to charge eligible patients more than the dentist's filed fee or Delta Dental's established maximum plan allowance, and Delta Dental will pay such dentists based on the least of the actual fee, the filed fee, or Delta Dental’s established maximum plan allowance for the procedure(s). Claims for services provided by dentists who are neither Delta Dental Premier, Delta Dental PPO dentists, or Participating Specialists are paid based on the lesser of the dentist's actual charge or the prevailing fee.
NJM Member Benefits and Resources
Delta Dental of New Jersey is a part of Delta Dental Plans Association. Through our national network of Delta Dental companies, we offer dental coverage in all 50 states, Puerto Rico and other U.S. territories.
