Dental
Dental Plan 1:
$1,500 annual benefit maximum with up to $250 carryover feature.
Dental Plan 2:
$2,000 annual benefit maximum with up to $350 carryover feature + $2,000 child orthodontia lifetime maximum benefit.
How the Dental Plan Works
The Dental Plan provides a full range of coverage for all your and your family’s dental needs.
- You have access to both the Delta Dental PPO Network and the Delta Dental Premier Network. You’ll get more out of your plan when you select a Delta Dental PPO Network provider, found nationwide.
- You may see any dentist.
- When you use a Delta Dental network dentist, they file your claims automatically and you will not be responsible for anything billed over Usual & Customary.
- Non-network dentists may also bill you for charges exceeding the plan’s maximum allowable charges.
Dental Plan Options
| Highlights | Plan 1 | Plan 2 | ||
|---|---|---|---|---|
| Delta Dental PPO | Delta Dental Premier or Out of Network | Delta Dental PPO | Delta Dental Premier or Out of Network | |
| Calendar Year Deductible (Maximum of 3 per Family) | $75 | $100 | $50 | $75 |
| Preventive Services | 100% coinsurance(No deductible applies) | 100% coinsurance(No deductible applies) | 100% coinsurance(No deductible applies) | 100% coinsurance(No deductible applies) |
| Basic Services | 90% coinsurance | 80% coinsurance | 90% coinsurance | 80% coinsurance |
| Major Services | 60% coinsurance | 50% coinsurance | 60% coinsurance | 50% coinsurance |
| Child Orthodontia Services $2,000 Lifetime Maximum (for children under age 19) | N/A | N/A | 50% coinsurance | 50% coinsurance |
| Annual Benefit Maximum | $1,500 | $1,500 | $2,000 | $2,000 |
| Weekly Payroll Deduction Amount | ||||
| Employee Only | $4.72 | $6.12 | ||
| Employee + Spouse | $9.88 | $13.18 | ||
| Employee + Child(ren) | $11.97 | $16.14 | ||
| Employee + Family | $17.49 | $23.83 | ||
NOTE: See the Summary Plan Descriptions for all details, including plan limits, conditions and exclusions.
Maximum Carryover Feature: Carry Unused Benefits Forward
Dental Plan 1:
If at least one covered service is applied toward your maximum payment in a benefit year (your benefit maximum), and the total benefit paid does not exceed $500 in that benefit year, up to $250 will carry over to the next benefit year’s maximum payment. This carryover amount will accumulate from one benefit year to the next but will not exceed $1,000. If no covered services are paid during a benefit year, all accumulated carryover amounts from previous benefit years will be forfeited.
Dental Plan 2:
If at least one covered service is applied toward your maximum payment in a benefit year (your benefit maximum), and the total benefit paid does not exceed $625 in that benefit year, up to $350 will carry over to the next benefit year’s maximum payment. This carryover amount will accumulate from one benefit year to the next but will not exceed $1,250. If no covered services are paid during a benefit year, all accumulated carryover amounts from previous benefit years will be forfeited.