PPO Plan I Generous Annual Maximum! No Deductibles
Covered Services Fee Schedule
Gives you peace of mind so you'll never have to worry about having a healthy smile.
Your Delta Dental benefits include coverage at all levels of service—from routine cleanings to root canals. You can go to any licensed dentist, however, you may save on out-of-pocket costs by going to a Delta Dental PPO dentist. In the event that treatment is rendered from a dentist who does not participate, the patient may be responsible for more than the percentage indicated below.
The information on this site is an overview of benefits and not a guarantee of payment. The following summary is a sample of benefits. Policies have exclusions and limitations that may limit coverage. For complete coverage details, please refer to your policy (in Oregon, refer to policy INVD-100A-Delta). These dental plans are available exclusively to members of organizations offering Delta Dental to them. Products and services referred to in this brochure are not available in all states or jurisdictions.
|Plan I Covered Services|
Plan I—The payment is based on the participating status of the dentist: Delta Dental PPO—based on dentist’s submitted fee or the Delta Dental PPO dentist fee schedule, whichever is less; Delta Dental Premier—based on dentist’s submitted fee or the maximum approved fee, whichever is less; and non-par—based on dentist’s submitted fee or Delta Dental’s nonparticipating dentist fee, whichever is less.
and in New York by:
|Delta Dental PPO Dentist||Delta Dental Premier or Non Participating||Waiting Periods|
|Class I Benefits|
|Diagnostic and preventive services* - Used to evaluate existing conditions and/or to prevent dental abnormalities or diseases (includes exams and cleanings twice per year, bitewing X-rays, and fluoride treatments to age 14)||90%||70%||None|
|Emergency palliative treatment* - Used to temporarily relieve pain||90%||70%||None|
|Radiographs/Diagnostic Imaging* - X-rays as required for routine care or as necessary for the diagnosis of a specific condition||90%||70%||6 months|
|Class II Benefits|
|Periodontal Prophylaxis - Periodontal maintenance following active periodontal therapy||80%||80%||6 months|
|Denture Repair - Relines and repairs to bridges, removable bridges, partial dentures, and complete dentures||80%||80%||6 months|
|Minor Restorative Services - Used to repair teeth damaged by disease or injury (for example, silver fillings and white fillings)||50%||50%||6 months|
|Class III Benefits|
|Oral Surgery Services - Extractions and dental surgery, including local anesthesia, suturing, if needed, and routine post-operative care||50%||50%||12 months|
|Endodontic Services - Used to treat teeth with diseased or damaged nerves (for example, root canals)||50%||50%||12 months|
|Periodontic Services - Used to treat diseases of the gums and supporting structures of the teeth||50%||50%||12 months|
|Prosthodontic Services - Used to replace missing natural teeth (for example, bridges and dentures)||50%||50%||12 months|
|Crown and Cast Restorations - Tooth restorations including metal and porcelain crowns||50%||50%||12 months|
|TMD Treatment - Treatment for jaw and facial joint disorders||50%||50%||12 months|
|Maximums and Deductible|
|Contract Year Maximum||$1,600 per member|
|TMD Lifetime Maximum||$300 per member|
|Deductible (per contract year) *Deductible waived for these services||None|