Preventive Dental
The Preventive Plan incorporates the most basic level of dental care. Semi-annual cleanings and annual x-rays are included, as well as some sealants. This is ideal for people who have few or no dental/oral health concerns or issues. There is no maximum coverage amount per year.
| Service/Feature |
PPO |
Delta Premier |
Out of Network |
| Annual Max Benefit |
Unlimited |
Unlimited |
Unlimited |
| Annual Deductible |
$0 |
$0 |
$0 |
Diagnostic & Preventive
Exams, cleanings, x-rays, sealants |
Covered at 100% |
Covered at 100% |
Covered at 100% |
Comprehensive Dental
The Comprehensive Plan is the more traditional plan. It includes the same benefits as the Preventive Plan, but also includes additional services and coverage, such as fillings, extractions, prosthetics, and orthodontia. This is ideal for people with more complex dental/oral health concerns or issues. There are maximum coverage amounts per covered person per year, based on the network utilized.
| Service/Feature |
PPO |
Delta Premier |
Out of Network |
| Annual Max Benefit |
$2,000 |
$1,500 |
$1,000 |
Annual Deductible
Not applicable to preventive and diagnostic |
$0/person;
$0/family |
$25/person;
$75/family |
$50/person;
$150/family |
Diagnostic & Preventive
Exams, cleanings, x-rays, sealants |
Covered at 100% |
Covered at 100% |
Covered at 100% |
Basic Services
Fillings, emergency treatment for pain |
Covered at 80% |
Covered at 50% |
Covered at 50% |
Endodontics, Periodontics
Root canals |
Covered at 75% |
Covered at 50% |
Covered at 50% |
Oral Surgery
Extractions |
Covered at 75% |
Covered at 50% |
Covered at 50% |
Prosthetics
Dentures, bridges, implants |
Covered at 50% |
Covered at 50% |
Covered at 0% |
Major Restoratives
Crowns and crown repairs |
Covered at 50% |
Covered at 50% |
Covered at 0% |
Orthodontics
$1,000 lifetime maximum |
Covered at 50% |
Covered at 50% |
Covered at 0% |
The above tables are summaries only. The Certificate of Coverage will be used in case of error and for all claims processing.
