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.
Diagnostic and Preventive Benefits
(two cleanings per 12 month period)*
Basic Benefits (Usual, Customary, and Reasonable
$65 and up
$150 per family
$100 per family
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
Delta will pay 50% up to a lifetime maximum of $2,500
Premier Access and Western Dental only - not available through DaltaCare of SafeGuard
* 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.