Delta Dental PPOTM Individual – Basic Plan

Delta Dental PPOTM Individual – Basic Plan - Individual Plan

Individual Plan Starts At

$30.95 Month

Prices may vary by number of enrollees, age and ZIP Code. One-time enrollment fee: $10.00

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Program Summary

Delta Dental has worked to improve the oral health of Americans with a national network of more than 150,000 practicing dentists and over 330,000 locations.1

Once you enroll, you’ll get coverage for diagnostic and preventive care, including exams, cleanings and x-rays. This plan also covers services like fillings and simple tooth extractions.**

Plan Highlights**

  • 100% coverage for preventive dental care such as exams, cleanings and x-rays
  • $50 annual deductible per person
  • Basic Services (fillings, emergency treatment to relieve pain) covered at 50%
  • Root canals covered at 50%
  • Oral Surgery (Simple tooth extractions) covered at 50%
  • Prosthodontics (bridges, dentures, implants) are not covered under this plan
  • Major Services (crowns, inlays, onlays, cast restorations) are not covered under this plan
  • Orthodontics (braces) are not covered under this plan

Annual Maximum Benefit For Covered Services

  • $1,000 per person each calendar year. (This is the total amount per person your plan will pay toward the cost of dental care each year.)

Calendar Year Deductible

This is the amount you will pay per person each calendar year before your plan starts making payments for covered service.

  • Individual — $50
  • Family — $150

Waiting Period

Diagnostic & Preventive (D & P) Services No Waiting Period
Basic Services 6 months

Individual Plans start at $30.95 a month

Prices may vary by number of enrollees, age and ZIP Code. One-time enrollment fee: $10.00

Eligibility
Primary enrollee, spouse or domestic partner, eligible dependent children up to age 26.
Please consult the plan policy for descriptions.
Annual Deductibles and Maximums $50 per person each calendar year
$150 per family each calendar year
Annual Maximum per Calendar Year $1,000 per enrollee

Covered Services Delta Dental PPO dentists Non-Delta Dental PPO dentists
Diagnostic and Preventive (D&P) Services
Exams, cleanings, x-rays and sealants
100% 100%
Basic Services Fillings
emergency treatment to relieve pain
50% 50%
Endodontics
Root canals
50% 50%
Periodontics
Gum treatments
Not a benefit
Oral Surgery
Simple tooth extractions
50% 50%
Prosthodontics
Bridges, dentures, implants
Not a benefit
Major Services
Crowns, inlays, onlays, cast restorations
Not a benefit
Orthodontics
Adults and dependent children
Not a benefit

Waiting Periods
D&P Services None
Basic Services 6 Months

Reimbursement is calculated based on maximum contract allowances. This benefit information is only a summary and is not intended or designed to replace or serve as the plan policy. Limitations and/or waiting periods may apply for some benefits; some services may be excluded from the plan.

Disclaimers

*These rates may not apply to you.

**Please consult the plan Policy for a description of plan benefits, limitations and exclusions. In the event of any inconsistency between this document and the plan Policy, the terms of the Policy will prevail.

Delta Dental PPOtm is underwritten by Delta Dental Insurance Company in AL, DC, FL, GA, LA, MS, MT, NV and UT and by not-for-profit dental service companies in these states: CA — Delta Dental of California; PA, MD — Delta Dental of Pennsylvania; NY — Delta Dental of New York, Inc.; DE — Delta Dental of Delaware, Inc.; WV — Delta Dental of West Virginia, Inc. In Texas, Delta Dental Insurance Company provides a Dental Provider Organization (DPO) plan.

This benefit information is only a summary and is not intended to replace or serve as the plan Policy.

Delta Dental is a registered trademark of Delta Dental Plans Association.

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