2024 Delta Dental Enhanced PPO Plan #03366
Basics
Full-Time Employee * Contribution Per Pay Period
Employee Only $13.45
Employee & Spouse/Registered Domestic Partner $28.24
Employee & Child(ren) $24.21
Employee & Family $39.00
Employee & Spouse/Registered Domestic Partner $28.24
Employee & Child(ren) $24.21
Employee & Family $39.00
Part-Time Employee * Contribution Per Pay Period
Employee Only $24.00
Employee & Spouse/Registered Domestic Partner $50.39
Employee & Child(ren) $43.20
Employee & Family $69.59
Employee & Spouse/Registered Domestic Partner $50.39
Employee & Child(ren) $43.20
Employee & Family $69.59
Lifetime maximum
Orthodontia only: $1,500 per each covered member.
Plan Year
2024
Offered To
Employees
Body/Description
Delta Dental PPO is the dentist network for this plan. This plan pays in-network benefits when your care is either provided or authorized by your Delta Dental PPO network dentist. Basic procedures by a Premier or non Delta Dental dentist will be covered at a lower percentage.
If your network dentist does not provide or authorize your care, the charges are considered out-of-network.
You are encouraged to obtain a predetermination of benefits from Delta for services greater than $300, or for crowns or bridges.
This document is a summary. Please refer to the plan Evidence of Coverage (EOC) for more details.
Coinsurance
Network: Delta Dental PPO providers
- Preventive and diagnostic: 100% of the negotiated rate
- Basic procedures: 80% of the negotiated rate
- Major restorative procedures: 50% of the negotiated rate
Orthodontia 50% of the negotiated rate
Non-PPO Network: Delta Dental Premier or non Delta Dental providers
- Preventive and diagnostic: 100% of Premier dentist fee or 100% program allowance
- Basic procedures: 60% of Premier dentist fee or program allowance
- Major restorative procedures: 50% of Premier dentist fee or program allowance Orthodontia 50% of Premier dentist fee or program allowance
You are responsible for amounts not covered by the dental plan.
- Preventive and diagnostic: 100% of the negotiated rate
- Basic procedures: 80% of the negotiated rate
- Major restorative procedures: 50% of the negotiated rate
Orthodontia 50% of the negotiated rate
Non-PPO Network: Delta Dental Premier or non Delta Dental providers
- Preventive and diagnostic: 100% of Premier dentist fee or 100% program allowance
- Basic procedures: 60% of Premier dentist fee or program allowance
- Major restorative procedures: 50% of Premier dentist fee or program allowance Orthodontia 50% of Premier dentist fee or program allowance
You are responsible for amounts not covered by the dental plan.
Deductible
Network: $0 per individual/$0 per family each calendar year
Non-PPO network: $50 per individual/$150 family each calendar year
Non-PPO network: $50 per individual/$150 family each calendar year
Benefit Type
Dental
Annual maximum
Network: $3,000 per individual each calendar year
Non-PPO Network: $2,000 per individual each calendar year.
(Network and Non-PPO Network Maximum Combined for a total benefit of $2,000)
Diagnostic and Preventative services do not count towards annual maximum.
Non-PPO Network: $2,000 per individual each calendar year.
(Network and Non-PPO Network Maximum Combined for a total benefit of $2,000)
Diagnostic and Preventative services do not count towards annual maximum.
Cleanings
Preventive and Diagnostic service:
PPO or Premier Network Provider: 100%
Non-Network: 100% (deductible waived)
Plan allows up to three cleanings/year. The third cleaning applies to certain conditions including diabetics, pregnancy, those requiring periodontal maintenance and those in an active orthodontic treatment plan.
PPO or Premier Network Provider: 100%
Non-Network: 100% (deductible waived)
Plan allows up to three cleanings/year. The third cleaning applies to certain conditions including diabetics, pregnancy, those requiring periodontal maintenance and those in an active orthodontic treatment plan.
Fluoride treatments
Preventive and Diagnostic service:
PPO or Premier Network Provider: 100%
Non-Network: 100% (deductible waived)
Two per calendar year
PPO or Premier Network Provider: 100%
Non-Network: 100% (deductible waived)
Two per calendar year
Routine exams
Preventive and Diagnostic service:
PPO and Premier Network Provider: 100%
Non-Network: 100% (deductible waived)
Two per calendar year
PPO and Premier Network Provider: 100%
Non-Network: 100% (deductible waived)
Two per calendar year
Sealants
Basic procedures service for children to age 15:
PPO Network Provider: 80%
Premier or Non-Network: 60% after deductible
PPO Network Provider: 80%
Premier or Non-Network: 60% after deductible
X-rays
Preventive and Diagnostic service:
PPO or Premier Network Provider: 100%
Non-Network: 100% (deductible waived)
PPO or Premier Network Provider: 100%
Non-Network: 100% (deductible waived)
Orthodontia
Network: 50% of Delta's approved fee
Non-PPO Network: 50% of Delta's approved fee
Orthodontia lifetime maximum benefit of $1,500 (combined). Payments are made in two installments: Once banding has occurred and 12 months later. You must be enrolled in the Enhanced plan throughout the entire treatment.
Non-PPO Network: 50% of Delta's approved fee
Orthodontia lifetime maximum benefit of $1,500 (combined). Payments are made in two installments: Once banding has occurred and 12 months later. You must be enrolled in the Enhanced plan throughout the entire treatment.
Retainers
(Covered under the Orthodontia benefit)
PPO Network Provider: 50% of Delta's approved fee
Premier or Non-Network: 50% of Delta's approved fee
PPO Network Provider: 50% of Delta's approved fee
Premier or Non-Network: 50% of Delta's approved fee
Anesthesia
Basic procedures service:
PPO Network Providers: 80%
Premier or Non-Network: 60% after deductible
PPO Network Providers: 80%
Premier or Non-Network: 60% after deductible
Bridges
Major Restorative procedures service:
PPO Network Providers: 50%
Premier or Non-Network: 50% after deductible
PPO Network Providers: 50%
Premier or Non-Network: 50% after deductible
Crown
Major Restorative procedures service:
PPO Network Providers: 50%
Premier or Non-Network: 50% after deductible
PPO Network Providers: 50%
Premier or Non-Network: 50% after deductible
Dentures
Major Restorative procedures service:
PPO Network Providers: 50%
Premier or Non-Network: 50% after deductible
PPO Network Providers: 50%
Premier or Non-Network: 50% after deductible
Extractions
Basic procedures service:
PPO Network Providers: 80%
Premier or Non-Network: 60% after deductible
PPO Network Providers: 80%
Premier or Non-Network: 60% after deductible
Fillings
Basic procedures service:
PPO Network Provider: 80%
Premier or Non-Network: 60% after deductible
PPO Network Provider: 80%
Premier or Non-Network: 60% after deductible
Gingivectomy
Basic procedures service:
PPO Network Provider: 80%
Premier or Non-Network: 60% after deductible
PPO Network Provider: 80%
Premier or Non-Network: 60% after deductible
Gold restorations
(Inlays & Onlays only)
Major Restorative procedures service:
PPO Network Provider: 50%
Premier or Non-Network: 50% after deductible
Major Restorative procedures service:
PPO Network Provider: 50%
Premier or Non-Network: 50% after deductible
Implants
Major Restorative procedures service:
PPO Network Provider: 50%
Premier or Non-Network: 50% after deductible
PPO Network Provider: 50%
Premier or Non-Network: 50% after deductible
Inlays
Major Restorative procedures service:
PPO Network Provider: 50%
Premier or Non-Network: 50% after deductible
PPO Network Provider: 50%
Premier or Non-Network: 50% after deductible
Onlays
Major Restorative procedures service:
PPO Network Provider: 50%
Premier or Non-Network: 50% after deductible
PPO Network Provider: 50%
Premier or Non-Network: 50% after deductible
Oral surgery
Basic procedures service:
PPO Network Provider: 80%
Premier or Non-Network: 60% after deductible
PPO Network Provider: 80%
Premier or Non-Network: 60% after deductible
Periodontal surgery
Basic procedures service:
PPO Network Provider: 80%
Premier or Non-Network: 60% after deductible
PPO Network Provider: 80%
Premier or Non-Network: 60% after deductible
Prescription drugs
Not covered
Root canals
Basic procedures service:
PPO Network Provider: 80%
Premier or Non-Network: 60% after deductible
PPO Network Provider: 80%
Premier or Non-Network: 60% after deductible
Space maintainers
Preventive and Diagnostic service:
PPO or Premier Network Provider: 100%
Non-Network: 100% (deductible waived)
PPO or Premier Network Provider: 100%
Non-Network: 100% (deductible waived)
Splinting
Not covered
TMJ (Temporomandibular joint syndrome)
Not covered
X-rays
Preventive and Diagnostic service:
PPO or Premier Network Provider: 100%
Non-Network: 100% (deductible waived)
PPO or Premier Network Provider: 100%
Non-Network: 100% (deductible waived)