Quick facts
Deductible - PPO or Premier Dentist
$25 per Member total per Benefit Year
Deductible Family Max - PPO or Premier Dentist
$50 per family per Benefit Year
Maximum Payment - Delta Dental PPO or Premier Dentist
$1,750 per Member total per Benefit Year on all services, except diagnostic and preventive services, emergency palliative treatment, brush biopsy, X-rays, and orthodontic services
Diagnostic & Preventive Services
100%
Orthodontic Services
50%
Basic Services (Sealants, Fillings, Root Canals, Periodontics, Oral Surgery, etc.)
80%
Major Services (Crowns, Bridges, Dentures, Implants)
60%
Maximum Payment - Nonparticipating Dentist
$1,250 per Member total per Benefit Year on all services, except diagnostic and preventive services, emergency palliative treatment, brush biopsy, X-rays, and orthodontic services
More details (4)
Orthodontic Services Lifetime Maximum
$1,500 per Member total per lifetime
Deductible - Nonparticipating Dentist
$50 Deductible per Member total per Benefit Year
Deductible Family Max - Nonparticipating Dentist
$100 per family per Benefit Year
Orthodontic Age Limit
No Age Limit
Carrier contact
800-524-0149 — member services
Group number: 9678
Your member ID card: check the carrier website or app, or ask HR for a copy.
Plan documents
Confirm details with your carrier for current plan information.