Plan Information

Delta Dental Premier Dentists

This is an Indemnity plan, which allows you complete freedom of dentist choice. However, Delta Dental Premier participating dentists have agreed to file the claim for you and to accept the amount approved by Delta. Amount of claims are based on a percentage of the Usual, Customary and Reasonable Fees (UCR) charged by dentists in your area.

Delta Dental Fee Schedule
  Plan Pays
Year 1 Year 2 Year 3
Diagnostic & Preventive Procedures* Diagnostic:
Routine periodic examinations twice in a calendar year.

Dental prophylaxis (teeth cleaning) twice in a calendar year.

Bitewing and full mouth x-rays.
80% 90% 100%
Basic Procedures*
(6 month waiting period)
Amalgam fillings.

Space Maintainers, recementation of crowns.
60% 70% 80%
Major Procedures*
(12 month waiting period)
Pulpal therapy and root canals.

Treatment of diseases of the gums.

Oral Surgery:
Extractions and other oral surgery, including pre and post operative care.

Gold restorations, crowns, bridges, partials and complete dentures.

Pontics, repair of crowns and bridges, repair of full and partial dentures.
0% 40% 50%

* $25 Office Visit Copay per person per visit. NO DEDUCTIBLE for Diagnostic, Basic and Major Procedures

Annual Plan Maximum - $2000

Orthodontia Procedures**
(12 month waiting period)
($450 calendar year maximum)

($1500 lifetime maximum per person for this benefit)

Orthodontic benefits are only available for eligible dependent children.
0% 40% 50%
** Orthodontia Deductible: $150 lifetime.