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.
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.
Sanofi US Benefit Summary
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.
