Page 44 - Demo

DENTALPLANS | SummaryOfBenefits
DELTA DENTAL PPO
DELTA DENTAL HMO-TYPE PLAN
IN-NETWORK
OUT-OF-NETWORK
IN-NETWORK ONLY
Calendar Year Maximum Benefit
$2,000 per person
$2,000 per person
No maximum
Calendar Year Deductible
$60 per person (does not apply
to Type A services)
$60 per person (does not apply
to Type A services)
$0
Type A Covered Services:
Preventive and Diagnostic Services
100% of the network dentist contracted amount (subject to frequency limits)
100% of reasonable and customary charge
Most preventive services covered with no copay, most other services have copays, see benefit schedule for details*
Type B Covered Services:
Basic and Restorative Services
70% of the network dentist contracted amount after deductible
70% of reasonable and customary charge after deductible
Amalgam fillings covered with no copays, most other services have copays, see benefit schedule for details*
Type C Covered Services:
Major Restorative Services
50% of the network dentist contracted amount after deductible
50% of reasonable and customary charge after deductible
Most services have copays, see benefit schedule for details*
Dentures
Repairs and Adjustments
Initial Installation (Full or Partial)
Replacement Limit
Covered as Type B Covered as Type C
Once every 60 mos.
Covered as Type B Covered as Type C
Once every 60 mos
Services have copays, see benefit schedule for details* Once every 60 months
Orthodontic Services
Lifetime Maximum
50% of the network dentist contracted amount after deductible $2,500
50% of reasonable and customary charge after deductible $2,500
Services have copays, see benefit schedule for details* Maximum benefit period of 24 months
Teeth Whitening
Not Covered
Not Covered
Services have copays
*Delta Dental HMO-type Plan does not cover services provided by out-of-network dental providers. Copies of benefit plan materials are available to you via mail or email, and may be requested by calling Delta Dental. See page 25 for carrier contact information.
44 | Insurance Trust For Delta Retirees | 2021 Benefits & Resources Guide