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.
Delta Dental PPO plus Premier™ — High Plan
Group #04744
| 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 | $100 | $100 | $100 |
| Family aggregate | $200 | $200 | $200 |
| Preventive & Diagnostic | |||
| Exams (2 per calendar year per person plus 1 non-routine exam) | 100% | 100% | 100% |
| Cleanings (4 per calendar year per person) | 100% | 100% | 100% |
| Bitewing X-Rays | 100% | 100% | 100% |
| Fluoride Treatment (Frequency limitations apply) | 100% | 100% | 100% |
| Sealants, Space Maintainers | 100% | 100% | 100% |
| Periodontal Maintenance | 100% | 100% | 100% |
| Basic Services | |||
| Fillings (composite fillings on all teeth) | 80% | 80% | 80% |
| Simple Extractions | 80% | 80% | 80% |
| Root Canals (Endodontics) | 80% | 80% | 80% |
| Periodontics (Surgical), Oral Surgery | 80% | 80% | 80% |
| Repair of dentures | 80% | 80% | 80% |
| Major Services | |||
| Crowns & Gold Restorations | 50% | 50% | 50% |
| Bridgework, Full & Partial Dentures | 50% | 50% | 50% |
| Implants | 50% | 50% | 50% |
| Orthodontics (Children only to age 19) | |||
| Co-insurance | 50% | 50% | 50% |
| Lifetime maximum | $1,500 | $1,500 | $1,500 |
| Download | |||
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.
Delta Dental PPO plus Premier™ — High Plan
Delta Dental of Connecticut 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.
