Dental Benefits

Delta Dental gives you the opportunity to visit the dentist of your choice on a treatment-by-treatment basis. You will have access to two networks of participating dentists, or you may visit a dentist outside of the network.

The plan also provides additional services if eligible, to help reduce risks associated with periodontal disease and certain medical conditions, including brush biopsies for earlier detection of oral cancer (see Healthy Smiles, Healthy Lives under Dental for details).

Benefit	Delta Dental PPO	Delta Dental Premier	Out-of-Network
Diagnostic and Preventative Services Oral exams (all types) twice per calendar year Bitewing and Periapical x-rays as needed Full-mouth x-rays once in any 36 consecutive months Cleanings (all types) twice per calendar year Fluoride, once per calendar year for dependents under the age 19 Emergency palliative treatment Space maintainers, once in 5 years to age 16	100%	100%	100%
Basic Services Fillings, including composite fillings on all teeth Periodontics: treatment for diseases of gums and bone supporting the teeth Endodontics: root canal filling and pulpal therapy Sealants for dependent children under 19, once per tooth every 5 years, limited to non-decayed first and second permanent molars Simple and surgical extractions	90%	80%	80%
Major Services Oral surgery, except for extractions covered under Basic Prosthetics: bridges and dentures; replacement will be covered only once in 5 years, but not during the first 12 months of coverage Crowns, jackets, labial veneers, inlays and onlays when required for restorative purposed, once in 5 years	60%	50%	50%
Orthodontic Services (For dependent children to age 19 who begin treatment while covered by this plan)	50%	50%	50%
Calendar Year Deductible (Individual/Family)	$50/$150	$50/$150	$50/$150
Calendar Year Maximum Per Person	$1,500+ MAXAdvantage	$1,500+ MAXAdvantage	$1,500+ MAXAdvantage
MAXAdvantage - Claims paid for exams, cleanings, x-rays and fluoride treatment do not apply to your calendar year benefit maximum.
Orthodontic Lifetime Maximum (per eligible dependent child)	$1,500	$1,500	$1,500

Healthy Smiles, Healthy Lives

Healthy Smiles, Healthy Lives provides those eligible with additional services to help reduce the risks associated with periodontal disease and certain medical conditions. Eligible medical conditions include: periodontal disease, pregnancy, diabetes, suppressed immune systems due to chemo and/or radiation treatment, HIV infection, organ transplant and/or stem cell transplant. Please see flyers in the Downloads section for more details.

Downloads

Summary of Benefits

Summary Plan Description

Web and Mobile Flyer

Healthy Smiles Healthy Lives Member flyer

Healthy Smiles Healthy Lives Member self-report form

Group Number

21171000

Provided By

Delta Dental

Provider Website

https://deltadental.com