Delta Dental PPO™ Individual Basic Plan

Dental Dental PPO Individual Basic is a plan that covers a percentage of your costs for covered dental services. Once you enroll, you’ll get coverage for diagnostic and preventive care, including exams, cleanings and x-rays. This plan also covers services like fillings and simple tooth extractions. ***Plus, receive savings on LASIK™ eye surgery through Qualsight™ and hearing benefits through Amplfon™.

Here are some plan benefits.

Preventive care

Cleanings, exams and x-rays are covered at 100% right away

Basic procedures

Basic services are covered at 50% with in-network dentist (after deductible)

Annual maximum benefit

$1,000 annual maximum

Annual deductible

$50 per person; $150 per family

Waiting periods

None for preventive services; 6 months for basic services

Choose any dentist

Visit any licensed dentist, though you’ll generally save more by visiting a dentist from our PPO network

Now let’s see what this plan includes.

Plan Highlights

Eligibility

Primary enrollee, spouse or domestic partner, eligible dependent children up to age 26.
**Please consult the plan policy for descriptions.

Deductibles and Maximums

Calendar Year Deductible	$50 Per enrollee
	$150 Per family
Annual Maximum per Calendar Year	$1,000 Per enrollee
Orthodontic Deductible	N/A
Orthodontic Lifetime Maximum	N/A

Covered Services

Delta Dental
PPO dentists

Non-Delta Dental
PPO dentists

Diagnostic and Preventive (D&P) Services
Exams, cleanings, x-rays and sealants

100%

Basic Services
Fillings, emergency treatment to relieve pain

50%

Periodontics
Gum treatments

Not a benefit

Oral Surgery
Simple tooth extractions

50%

Prosthodontics
Bridges, dentures, implants

Not a benefit

Major Services
Crowns, inlays, onlays, cast restorations

Not a benefit

Orthodontics
Adults and dependent children

Not a benefit

Waiting Periods

Diagnostic and Preventive Services	None
Basic Services	6 Months
Major Services	N/A
Orthodontics	N/A

Reimbursement is calculated based on maximum contract allowances. This benefit information is only a summary and is not intended or designed to replace or serve as the plan Policy. Limitations and/or waiting periods may apply for some benefits; some services may be excluded from the plan.

Additional Plan Information For Delta Dental PPO Individual Basic Plan

Annual Maximum

This is the maximum amount that the plan will pay in a calendar year.

$1000, per enrollee on the plan

Calendar Year Deductible

This is the amount you will pay out-of-pocket for services in a calendar year.

Individual – $50
$150 annual deductible for families.
Family $150

Choose any dentist

Visit any licensed dentist, anywhere. You’ll generally save the most by visiting a dentist from our PPO network. These dentists agree to reduced fees, and won’t charge you more than your expected share of the bill. They also complete your claim forms and can advise you on questions about your share of the payment. You can use Find a Dentist on this page to easily locate a PPO dentist.

*These rates may not apply to you.

**Please consult the plan Policy for a description of plan benefits, limitations and exclusions. In the event of any inconsistency between this document and the plan Policy, the terms of the Policy will prevail.

Delta Dental PPO™ plans are underwritten by Delta Dental Insurance Company in AL, DC (Policy IENT-P-CORE-DC-R22), FL, GA, LA, MS, MT, NV and UT and by not-for-profit dental service companies in these states: CA — Delta Dental of California; PA, MD — Delta Dental of Pennsylvania; NY — Delta Dental of New York, Inc.; DE — Delta Dental of Delaware, Inc.; WV — Delta Dental of West Virginia, Inc. In Texas, Delta Dental Insurance Company provides a Dental Provider Organization (DPO) plan.

West Virginia: Learn about our commitment to providing access to a quality dentist network at deltadentalins.com/about/legal/index-enrollee.html.

This benefit information is only a summary and is not intended to replace or serve as the plan Policy.

***Vision corrective services and Amplifon’s hearing health services are not insured benefits. Delta Dental makes the vision corrective services program and hearing health care services program available to provide access to the preferred pricing for LASIK surgery, hearing aids and other hearing services.

Delta Dental is a registered trademark of Delta Dental Plans Association.

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