1. Overview
This dental plan provides comprehensive coverage through the Delta Dental PPO plus Premier network. You may visit any licensed dentist, but costs are lowest when using a Delta Dental PPO provider.
Plan coverage includes:
- Diagnostic & Preventive Services
- Basic Services
- Major Services
- Pediatric coverage through Right Start 4 Kids®
2. Annual Deductible
- Individual: $50
- Family: $150
- Deductible applies only to Basic and Major services.
3. Annual Maximum
- $1,500 per individual, per calendar year.
4. Orthodontic Coverage
- Orthodontic services are not included in this plan.
5. Prevention First
- Diagnostic and Preventive services do not apply toward the deductible.
- These services also do not count toward your annual maximum when using PPO or Premier providers.
6. Network Coverage Levels
| Service Type | PPO Provider | Premier Provider | Out‑of‑Network |
|---|
| Diagnostic & Preventive | 100% | 80% | 80% |
| Basic Services | 80% | 50% | 50% |
| Major Services | 50% | 50% | 50% |
| Orthodontics | Not Included | Not Included | Not Included |
7. Diagnostic & Preventive Services
Oral Exams & Cleanings
- Covered twice per calendar year.
- Up to two additional cleanings allowed with qualifying Evidence‑Based Dentistry conditions.
Problem‑Focused Exams
- Up to two per calendar year, in addition to routine exams.
Screenings
- Two per calendar year, in addition to routine exams.
Sealants
- One per permanent posterior molar every three years through age 19.
Bitewing X‑Rays
- Covered once per calendar year, including vertical bitewings.
Full‑Mouth X‑Rays
- Covered once every five years (more frequently when medically necessary).
Fluoride Treatments
- Covered twice per year; no age limit.
Space Maintainers
- One per quadrant per lifetime, through age 19.
8. Basic Services
Fillings
- Posterior composite fillings limited to one per tooth and surface every five years.
Oral Surgery
- Includes extractions and related services.
Endodontics & Periodontics
- Periodontal cleanings are limited to four total cleanings per year.
Anesthesia
- General anesthesia, IV sedation, or nitrous oxide covered up to one hour when performed with certain surgical procedures.
9. Major Services
Denture Repair & Reline
- Once every three years per appliance.
Crowns & Implants
- Covered once every seven years.
- Crowns not covered under age 12; implants not covered under age 16.
Dentures & Bridges
- Covered once every seven years; not covered under age 16.
Occlusal Guards
- One guard every five years.
- Adjustments covered once per year after six months from initial placement.
10. Pediatric Coverage – Right Start 4 Kids®
Children under age 13 receive:
- 100% coverage for Diagnostic & Preventive, Basic, and Major services
- No deductible
- Coverage applies only when visiting a PPO or Premier provider
- Out‑of‑network services receive adult coverage levels
11. Provider Billing Notes
- PPO providers bill according to the PPO allowable fee.
- Premier providers bill according to the Maximum Plan Allowance (MPA).
- Out‑of‑network providers may bill above the MPA; members are responsible for the difference (balance billing).
- You will receive the best benefit by choosing a PPO provider.
12. FAQs
How many cleanings can I receive each year?
Two routine cleanings, plus up to two additional cleanings for qualifying conditions.
Are orthodontic services covered?
No, orthodontic coverage is not included.
Do I have to stay in‑network?
No, but using a PPO provider offers the lowest out‑of‑pocket cost.
- Open enrollment applies annually.
- The official employee benefits booklet governs if discrepancies exist.