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2017 Benefits Book

Delta Dental PPO SM plus Premier Coverage effective January 1, 2017

Non-Participating Dentist

Delta Dental PPO Dentist

Delta Dental Premier ® Dentist

Plan Pays

Plan Pays

Plan Pays

Diagnostic & Preventive

Diagnostic and Preventive Services – in- cludes exams, cleanings, fluoride, and space maintainers

100%

100%

100%

Sealants – to prevent decay of permanent teeth Occlusal Guard – bite guards and occlusal adjustments

100%

100%

100%

100%

100%

100%

Radiographs – X-rays

100%

100%

100%

Basic Services

Emergency Palliative Treatment – to temporarily relieve pain Minor Restorative Services – fillings and crown repair Endodontic Services – root canals Periodontic Services – to treat gum disease Oral Surgery Services – extractions and dental surgery Other Basic Services - misc. services Major Restorative Services – crowns Relines and Repairs - to bridges, dentures, and implants Prosthodontic Services – includes bridges, dentures, and implants

80%

80%

80%

80%

80%

80%

80%

80%

80%

80%

80%

80%

80%

80%

80%

80%

80%

80%

Major Services

50%

50%

50%

50%

50%

50%

50%

50%

50%

Orthodontics

Orthodontic Services – braces

Dependent children to age 26 Adult – In Network Coverage only

50% 50%

50% 50%

50%

0% There is a 1-year waiting period on Adult and Child Orthodontic services if you or your covered dependents did not enroll in the Dental Plan on the original date ofeligibility.

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