Sanofi US Benefit Summary
| Service | PPO Plus Premier |
|---|---|
| Calendar year maximum (per person) | $2,000 |
| Calendar Year Deductible (waived on Preventive & Diagnostic) | |
| Per person | $25 |
| Family aggregate | $75 |
| Orthodontic | $50 |
| TMJ/Jaw Disorder Lifetime Maximum | $1,000 |
| Preventive & Diagnostic | |
| Exams, Cleanings, Bitewing x‐rays (each twice in a calendar year) | 100% |
| Fluoride Treatment (once in a calendar year, children to age 19) | 100% |
| Sealants | 100% |
| Basic Services | |
| Simple Restorations | 80% |
| Endodontics (root canal) | 80% |
| Surgical Periodontics | 80% |
| General Periodontics | 80% |
| Simple Extractions | 80% |
| Major Services | |
| Crowns, Gold Restorations (over natural teeth) | 50% |
| Implants, Implant Related Services | 50% |
| TMJ Therapy, TMJ Appliance | 50% |
| Bridgework | 50% |
| Full and partial Dentures | 50% |
| Orthodontics | |
| Full comprehensive treatment | 50% |
| Lifetime maximum (Child only to Age 20) | $1,500 |
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.
