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Procedures
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Delta Preferred Option
Preferred Provider Organizaion (PPO)
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Important information about the Plan
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Benefits are paid based on allowable charges. Allowable charges are usual, customary and reasonable fees as determined by Delta Dental. You may use any licensed dentist, however, you will receive the maximum benefits available when you choose a PPO network dentist (refer to the PPO Directory). If you choose an out-of-network dentist, you will still benefit by selecting a Delta Dental participating dentist, as you are assured that his/her fees are within allowable charge limits.
All claims for services rendered must be submitted directly to Delta Dental for processing.
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| Deductible |
Network Dentist (PPO) - $40 per person, per calendar year; $120 maximum per family per calendar year.
Out-of-Network Dentist - $50 per person, per calendar year; $150 maximum per family per calendar year.
Deductible does not apply to diagnostic and preventative benefits
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| Annual Maximum |
In and Out of Network
$2,000 per person per calendar year
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| Diagnostic
Oral Examination, Full Mouth X-rays, Bitewing X-rays, Emergency treatment (during office hours)
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Network Dentist: Delta pays 100% of allowable charges
Out of Network Dentist: Delta pays 80% of allowable charges
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| Preventive
Prophylaxis, Topical fluoride, Space maintainers
Sealants (per tooth),
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Network Dentist: Delta pays 100% of allowable charges
Out of Network Dentist: Delta pays 80% of allowable charges
In and Out of Network: Delta pays 80% of allowable charges (deductible applies) |
| Periodontic
Subgingival curettage, Gingivectomy, Muco-gingival or osseous surgery
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In and Out of Network: Delta pays 80% of allowable charges |
| Endodontic
Pulp capping, Pulptomy, Root Canals, Apicoectomy
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In and Out of Network: Delta pays 80% of allowable charges |
| Restorative (other than crowns)
Amalgram - primary & permanent teeth
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In and Out of Network: Delta pays 80% of allowable charges |
| Crowns and Bridges
Crowns per unit -
- Full gold
- Predominately base metal
- Porcelain
- Pin Build-up, Post and core
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In and Out of Network: Delta pays 80% of allowable charges
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| Prosthodontics
Dentures - complete or partial, adjustments, reline (office) & rebase
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In and Out of Network: Delta pays 80% of allowable charges |
| Oral Surgery
Simple extractions, Surgical extractions Impactions, Frenectomy
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In and Out of Network: Delta pays 80% of allowable charges |
| Orthodontia
Full Banding
Retention
Records Fee
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Delta pays 80% of allowable charges, up to $1,000 lifetime maximum (child or adult)
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| TMJ Rider |
Delta pays 80% of allowable charges, up to $1,000 lifetime maximum |
| Emergency Out-of-Area Treatment |
Benefits are payable as indicated above |
