Delta Dental PPO plus Premier™ — Low 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 | $750 | $750 |
| Annual deductible (waived for Preventive & Diagnostic) | |||
| Per person | $50 | $100 | $100 |
| Family aggregate | $100 | $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% | 50% | 50% |
| Simple Extractions | 80% | 50% | 50% |
| Root Canals (Endodontics) | 80% | 50% | 50% |
| Periodontics (Surgical), Oral Surgery | 80% | 50% | 50% |
| Repair of dentures | 80% | 50% | 50% |
| Major Services | |||
| Crowns & Gold Restorations | 60% | 50% | 50% |
| Bridgework, Full & Partial Dentures | 60% | 50% | 50% |
| Implants | 60% | 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.
