Delta Dental PPO Plus Premier™ Plan
Group #09630
| Service | Delta Dental Premier® & Delta Dental PPO Dentists | Non-participating Dentists |
| Calendar Year Maximum (per person) | $1,250 | $1,250 |
| Calendar Year Maximum deductible (waived for Preventive & Diagnostic) | ||
| Per person | $50 | $100 |
| Family aggregate | $150 | $300 |
| Preventive & Diagnostic | ||
| Exams, Cleanings (2 per calendar year) | 100% | 100% |
| Bitewing X-Rays (2 per calendar year for age 18 and under, 1 per calendar year 19 and up) | 100% | 100% |
| Fluoride Treatment (2 per calendar year, children to age 19) | 100% | 100% |
| Sealants | 100% | 100% |
| Space Maintainers | 100% | 100% |
| Remaining Basic | ||
| Fillings, Extractions | 80% | 80% |
| Endodontics (Root Canal) | 80% | 80% |
| Periodontics, Oral Surgery | 80% | 80% |
| Repair of Dentures | 80% | 80% |
| Crown repairs | 80% | 80% |
| Crowns & Prosthodontics | ||
| Crowns, Gold Restorations (over natural teeth) | 60% | 50% |
| Bridgework | 60% | 50% |
| Full & Partial Dentures | 60% | 50% |
| Implants | 50% | 40% |
| Orthodontic Benefits, full comprehensive treatment (child only) | ||
| Co-insurance | 50% | 50% |
| Lifetime maximum | $1,500 | $1,500 |
Your dentist's network will impact how much you pay. Dentists that 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.
