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.
Tata Consultancy Services Benefits Overview - low plan
Delta Dental PPO Plus Premier (TX, MT, MS, LA)
PPO Network
Using a PPO provider is considered in network and will offer you the greatest savings on dental services which will spread your annual maximum further.
Premier Network
Using a Premier provider is considered in network but will not offer as robust savings as the PPO network. It is the largest network.
Out of Network
You have the freedom to choose any dentist that does not participate in either of the above networks. Claims will be reimbursed at the 90th UCR level but there may be balance billing and your maximum will not go as far.
| In-Network | Out-of-network | ||
|---|---|---|---|
| Service | If a Delta Dental PPO Network Dentist is used | If a Delta Dental Premier Dentist is used | If a Non-participating Dentist is Used |
| Annual maximum (per person) | $1,500 | $1,500 | $1,500 |
| Annual deductible (waived for Preventive & Diagnostic) | |||
| Per person | $50 | $50 | $50 |
| Family aggregate | $150 | $150 | $150 |
| Preventive & Diagnostic | |||
| Exams (Frequency limitations apply) | 100% | 100% | 100% |
| Cleanings (Frequency limitations apply) | 100% | 100% | 100% |
| Bitewing X-Rays | 100% | 100% | 100%; |
| Fluoride Treatment (Frequency limitations apply) | 100% | 100% | 100% |
| Sealants, Space Maintainers | 100% | 100% | 100% |
| Basic Services | |||
| Fillings | 80% | 80% | 80% |
| Simple Extractions | 80% | 80% | 80% |
| Root Canals (Endodontics) | 80% | 80% | 80% |
| Repair of dentures | 80% | 80% | 80% |
| Major Services | |||
| Crowns & Gold Restorations | 50% | 50% | 50% |
| Bridgework, Full & Partial Dentures | 50% | 50% | 50% |
| Periodontics (Surgical), Oral Surgery | 50% | 50% | 50% |
| Periodontal Maintenance | 50% | 50% | 50% |
| Implants | 50% | 50% | 50% |
| Orthodontics (Adult and Child) | |||
| Co-insurance | 50% | 50% | 50% |
| Lifetime maximum | $1,000 | $1,000 | $1,000 |
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.
Tata Consultancy Services 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.
