Plan Information

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.

Underwritten by:
Renaissance Life & Health Insurance Company of America
P.O. Box 1596
Indianapolis, IN 46206

and in New York by:
Renaissance Health Insurance Company of New York
New York, NY

  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