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.
Webster Bank Delta Dental PPO plus Premier™ - Basic Plan
Group #4759
| Service | In-Network If a Delta Dental PPO or Premier Dentist is Used |
Out-of-Network If a Non-Participating Dentist is Used |
|---|---|---|
| Calendar year maximum (per person) | $1,500 | $750 |
| Calendar year deductible (waived on Preventive & Diagnostic) | ||
| Per person | $100 | $100 |
| Family aggregate | $300 | ;$300 |
| Preventive & Diagnostic | ||
| Exams, Cleanings (2 per calendar year) | 100% | 80% |
| Bitewing X-rays (2 per calendar year to age 18; 1 per calendar year for 19+) | 100% | 80% |
| Fluoride treatment (2 per calendar year to age 18) | 100% | 80% |
| Full mouth X-rays (1 per 5 years) | 100% | 80% |
| Basic Services (after deductible) | ||
| Fillings (composite fillings on all teeth) | 80% | 50% |
| Simple Extractions | 80% | 50% |
| Non-surgical Periodontics, Periodontal maintenance (4 per calendar year; interchangeable with cleanings) | 80% | 50% |
| Cone Beam X-Rays | 80% | 50% |
| Sealants | 80% | 50% |
| Space maintainers | 80% | 50% |
| Oral surgery | 80% | 50% |
| Athletic mouth guards | 80% | 50% |
| Major Services | ||
| Crowns, Inlays, Onlays, Bridgework | 50% | 50% |
| Full and Partial Dentures | 50% | 50% |
| Repair of dentures | 50% | 50% |
| Root canals (Endodontics) | 50% | 50% |
| Surgical Periodontics | 50% | 50% |
| Implants | 50% | 50% |
| Orthodontics (Adult and Child) | ||
| Co-insurance | Not a benefit | Not a benefit |
| Lifetime maximum | N/A | N/A |
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.
Webster Bank Member Benefits and Resources
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.
