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Coverage and Costs for Certain Procedures: Indemnity and Paid Provider Option (PPO)

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.
 
 
Comparison of Dental Plan Benefits
Type of PlanDelta Dental PPO plus Premier  Delta Dental PPO plus Premier PPO/using Participating Provider1PPO/using Non-Participating Provider
Who is CoveredRetireesDependents of RetireesRetirees and DependentsRetirees and Dependents

Diagnostic and Preventive Benefits (two cleanings annually)

No charge2No charge2No charge2,320%3
Basic Benefits10%20%10%20%
Crowns20%50%20%*50%
Bridges, Full & Partial Dentures50%50%40%50%
Implant BenefitN/AN/AWill pay 50% up to a lifetime maximum of $2,500Will pay 50% up to a lifetime maximum of $2,500
OrthodontiaWill pay up to 50% of approved fee for orthodontia, with a lifetime maximum for this benefit of $1,000 for retireeWill pay up to 50% of approved fee for orthodontia, with a lifetime maximum for this benefit of $1,000 for dependentsWill pay up to 50% of approved fee, with a lifetime maximum of $1,000 for each adult and $1,500 for dependent childrenWill pay up to 50% of approved fee, with a lifetime maximum of $1,000 for each adult and $1,000 for dependent children
Annual Deductible$50$50 per person$25 per person$75 per person
Maximum Deductible$50$150 per family$100 per family$200 per family
Annual Maximum$2,000$1,000$2,000$1,000
 
1.  Diagnostic and Preventive Benefits are exempt from the deductible. 
2.  The level of benefits and covered services reflected in the chart are based on services provided by a PPO Plan dentist; for services provided by a non-PPO plan dentist, the level of benefits is lower.
3.  The PPO includes a third cleaning for high-risk patients.
 
  Updated: 8/16/2017
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