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| Delta Dental Benefits | |||
|---|---|---|---|
| Delta Dental PPO Network Provider | Delta Dental Premier Network Provider | Non Network* Provider | |
| Annual Benefit Maximum | $1,700 per member | ||
| Lifetime Orthodontic Benefit Maximum | 50% Coinsurance to a $1,000 per member | ||
| DEDUCTIBLE | |||
| Diagnostic and Preventive Services | No Deductible | ||
| Basic Restorative Services | $50 per person per Plan year Not to exceed an annual family deductible of $150 |
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| Major Restorative Services | |||
| COINSURANCE | |||
| BASIC BENEFIT Applies when you have NOT had at least one routine prophylaxis (cleaning) and/or preventive oral exam in prior 12 months |
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| Diagnostic and Preventive Services | Allowed Amount covered in full by the Plan* | ||
| Basic Restorative Services | 50% | 50% | 50% |
| Major Restorative Services | 50% | 50% | 50% |
| ENHANCED BENEFIT Applies when you have had at least one routine prophylaxis (cleaning) and/or preventive oral exam in prior 12 months |
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| Diagnostic and Preventive Services | Allowed Amount covered in full by the Plan* | ||
| Basic Restorative Services | 20% | 40% | 40% |
| Major Restorative Services | 50% | 50% | 50% |
*Services by Non Network providers are subject to the Allowed Amount including the Maximum Plan Allowance for Non Network Providers. Any amounts in excess of the Allowed Amount will be the member’s responsibility.
Your Coinsurance will increase for Basic Restorative Services when you have not had a routine prophylaxis (cleaning) and/or preventive oral exam in the preceding twelve (12) month period. Ninety (90) days following receipt of a qualifying prophylaxis (cleaning) or preventive oral exam, you will qualify for the Enhanced Benefit Level. The Plan reserves the right to determine what services will qualify as meeting the definition of a routine prophylaxis (cleaning) and preventive oral exam. Routine prophylaxis (cleanings) and preventive exams shall not include any services provided on an emergency basis or for treatment of an injury to the teeth.