Benefits Book 2018

201 8 Benefits Book

Delta Dental PPO SM plus Premier

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.

Did you know? Preventive dental services by a Non-Network dentist will be paid at 90% of UCR after a $50 deductible in 2019. SAVE MONEY by visiting a Delta Dental Provider.

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