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DENTAL

The dental plan is administered by Delta Dental.

The following is a summary of your dental benefits. For a more detailed explanation of benefits, please refer to your Summary Plan Description (SPD), certificate of coverage or benefit summary.

  PPO Dentist Premier Dentist Non-Participating Dentist*
Annual Deductible $25 per person / $50 per family (regardless of network)
Preventive Care
Exams and Cleanings (once every 6 months)
X-rays
100% 100% 100%
Basic Care
Fillings
Extraction
Repair of crowns, bridges, dentures
80% 80% 80%
Major Care
Single crowns, bridges & dentures
50% 50% 50%
Annual Maximum Benefit $1,500
Orthodontia Lifetime Maximum
(all ages)
$1,500

* When you receive services from a Non-participating Dentist, the percentages in the column indicate the portion of Delta Dental’s Non-participating Dentist Fee that will be paid for those services. This amount may be less than what the Dentist charges or Delta Dental approves, and you are responsible for that difference.

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