Delta Dental PPOTM Individual – Premium Plan

Delta Dental PPOTM Individual – Premium Plan - Individual Plan

Individual Plan Starts At

$64.95 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 preventative care (D&P), including routine exams, cleanings and x-rays. This plan also covers basic services like fillings and tooth extractions, as well as major restorative treatments such as root canals, crowns, inlays, dental implants, braces, bridges and dentures. **

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 80%.
  • Root canals covered at 50%.
  • Oral Surgery (Simple tooth extractions) covered at 50%.
  • Prosthodontics (bridges, dentures, implants) covered at 50%.
  • Major Services (crowns, inlays, onlays, cast restorations) covered at 50%.
  • Orthodontics (braces) covered at 50%.
  • $1,500 maximum lifetime benefit for each covered person for orthodontic care.

Annual Maximum Benefit for Covered Services

  • $1,500 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 services.

  • Individual — $50
  • Family — $150

Family Plan

Family plan includes the primary enrollee and can include a spouse or domestic partner and eligible dependent children up to age 26.


Waiting Period***

Diagnostic & Preventive (D & P) Services No Waiting Period
Basic Services 6 months
Major Services 12 months
Orthodontics 12 months

Individual Plans start at $64.95 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 $1,500 Per enrollee
Orthodontic Deductible $50
Orthodontic Lifetime Maximum $1,500

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
80% 80%
Endodontics
Root canals
50% 50%
Periodontics
Gum treatments
50% 50%
Oral Surgery
Simple tooth extractions
50% 50%
Prosthodontics
Bridges, dentures, implants
50% 50%
Major Services
Crowns, inlays, onlays, cast restorations
50% 50%
Orthodontics
Adults and dependent children
50% 50%

Waiting Periods
D&P Services None
Basic Services 6 Months
Major Services 12 Months
Orthodontics 12 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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