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Dental Cost Comparison

The following chart provides a comparison of costs for certain procedures covered by the State-sponsored dental plans. Please consult each dental plan's Evidence of Coverage for detailed information and plan limitations.

For each plan, shows the reimbursement amount for each procedure.
For these procedures Delta PPO plus
Premier Basic
Rank and File Employees
Delta PPO plus
Premier Basic
Dependents of Rank and File Employees
Delta Dental PPO plus Premier Enhanced
Excluded Employees and Dependents
Delta Dental
**Preferred Provider Option
Excluded and Rank and File Employees and Dependents
SafeGuard
DeltaCare USA
Premier Access
Western Dental
Standard
Excluded and Rank and File Employees and Dependents
SafeGuard
***Enhanced
Excluded Employees and Dependents

Diagnostic and Preventive Benefits

(two cleanings per 12 month period)*

0

0

0

0

0

0

Basic Benefits (Usual, Customary, and Reasonable

​10%

20%

​10%

10%

​0

​0

Crowns ​20% ​50% ​20%* ​20%* ​$50 ​0
Bridges, Full and Partial Dentures

​50%

​50%

​50%

​40%

​$65 and up

​0

Annual Deductible

​$50*

​$50*

​$25*

​$25*

​No deductible

​No deductible

Maximum Deductible

​$150 per family

​$150 per family

​$100 per family

​$100 per family

​N/A

N/A

Orthodontia

​Delta will pay 50% up to a lifetime maximum of $1,000 per person

​Delta will pay 50% up to a lifetime maximum of $1,000 per person

​Delta will pay 50% up to a lifetime maximum of $1,000 per person

​Delta will pay 50% up to a lifetime maximum of $1,000 per adult and pay 50% up to a lifetime of $1,500 per child

​$1,000 plus up to $250 start-up costs

​$1,000 plus up to $250 start-up costs

Implant Benefit

​N/A****

​N/A****

​N/A****

​Delta will pay 50% up to a lifetime maximum of $2,500

​Premier Access and Western Dental only - not available through DaltaCare of SafeGuard

​N/A****

Annual Maximum

​$2,000

​$1,000

​$2,000

​$2,000

​No Maximum

No Maximum​

* Diagnostic and Preventive Benefits are exempt from the deductible.

** The level of benefits and covered services reflected in the chart are based on services provided by a PPO Network dentist. The level of benefits and covered services provided by a non-PPO dentist are lower. Additionally, the PPO includes up to a $2,500 lifetime benefit for dental implants and a 3rd cleaning for high-risk patients. High-risk patients include: pregnant women, cancer chemotherapy patients, and persons with compromising systemic diseases such as AIDS, diabetes, endocarditis, or persons who have had organ transplants.

*** The SafeGuard enhanced coverage provides for three cleanings per 12-month calendar year service period instead of the normal two cleanings. Excluded employees and their dependents have the enhanced coverage under SafeGuard. Rank and File employees and their dependents have the standard coverage under SafeGuard.

**** Not Available.

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