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.
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Delta Dental PPO plus Premier™
Group #4725
| Service | Low | Medium | High |
|---|---|---|---|
| Calendar year maximum (per person) | $750 | $1,250 | $2,000 |
| Calendar year deductible (waived on Preventive & Diagnostic) | |||
| Per person | $0 | $25 | $50 |
| Family aggregate | $0 | $75 | $150 |
| Preventive & Diagnostic | |||
| Exams, Cleanings (2 per calendar year) | 100% | 100% | 100% |
| Bitewing X-rays | 100% | 100% | 100% |
| Fluoride treatment (2 per calendar year to age 19) | 100% | 100% | 100% |
| Full mouth X-rays (1 per 5 years) | 100% | 100% | 100% |
| Basic Services (after deductible) | |||
| Fillings, extractions | 80% | 80% | 80% |
| Endodontics, Periodontal | 80% | 80% | 80% |
| Oral surgery | 80% | 80% | 80% |
| Crowns & Prosthodontics (after deductible) | |||
| Crowns, Inlays, Onlays, Bridgework | Not covered | 50% | 50% |
| Full and Partial Dentures | Not covered | 50% | 50% |
| Implants | |||
| Co-insurance | N/A | N/A | 50% |
| Lifetime maximum (per patient: Adult & Child, to age 26) | N/A | N/A | $3,500 |
| Orthodontics (Adult and Child) | |||
| Co-insurance | N/A | N/A | 50% |
| Lifetime maximum | N/A | N/A | $2,000 |
| Download | Download | 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 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.
