Delta Dental PPO/Premier Non-Delta Dental Dentists $1,000 Maximum Per Plan Year $50 per individual / $100 per family Deductible per plan year Diagnostic 100% 100% Exams and X-rays Preventive 100% 100% Routine Cleanings and Flouride Treatment Restorative Protective Restoration (benefit is limited to once per tooth 80% 80% within a 3 month period). * Post Removal (benefit is limited to once per tooth within a 5 50% 50% year period). * Inlay/Onlay 50% 50% Benefit is limited to once per tooth within a 5 year period.* Crowns Stainless Steel – 50% 50% Limitations may apply. * Crowns - Single Benefit is limited to one crown per tooth within a 5 year 80% 80% period. Additional limitations may apply. * Other Restorative Services Re-cement or re-bond inlay/onlay/veneer or partial coverage Restoration, Pin retention, crown repair, reattachment, . 50% - 80% depending upon procedure 50% - 80% depending upon procedure Limitations apply. * Resin-based Composite - direct 80% 80% Limitations apply. * Amalgams 80% 80% Limitations apply. * *To view limitations and further benefit details, logon to the Delta Dental website above. Your enrollee ID is your Social Security Number.
Delta Dental PPO/Premier Non-Delta Dental Dentists Maximum Per Plan Year $1,000 Deductible per plan year $50 per individual / $100 per family Diagnostic Exams and X-rays 100% 100% Preventive Routine Cleanings and Flouride Treatment 100% 100% Restorative Protective Restoration (benefit is limited to once per tooth within a 3 month period). * Post Removal (benefit is limited to once per tooth within a 5 year period). * 80% 50% 80% 50% Inlay/Onlay Benefit is limited to once per tooth within a 5 year period.* 50% 50% Crowns – Stainless Steel Limitations may apply. * 50% 50% Crowns - Single Benefit is limited to one crown per tooth within a 5 year period. Additional limitations may apply. * 80% 80% Other Restorative Services Re-cement or re-bond inlay/onlay/veneer or partial coverage Restoration, Pin retention, crown repair, reattachment, . Limitations apply. * 50% - 80% depending upon procedure 50% - 80% depending upon procedure Resin-based Composite - direct Limitations apply. * 80% 80% Amalgams Limitations apply. * 80% 80% *To view limitations and further benefit details, logon to the Delta Dental website above. Your enrollee ID is your Social Security Number.
2019PlanHighlights.docx