Primary enrollee, spouse and eligible dependent children to the end of the month dependent turn age 26.
Principal Benefits And Covered Services
|Deductibles And Benefits
|$50 per person, $150 per family per calendar year. The maximum benefit paid per the calendar year is $2,000 per person|
|Diagnostic And Preventive
Benefits* - oral examinations, cleanings, x-rays biopsy/tissue examinations, fluoride treatment, space maintainers, specialist consultation
|100% of Delta dentist’s fee (no deductible applies for these services)|
|Basic Benefits – oral surgery (extractions), fillings, root canals, periodontic (gum) treatment, sealants||80% of Delta dentist’s fee|
|Crowns, Jackets, And Cast Restorations||80% of Delta dentist’s fee|
|Prosthodontic Benefits – bridges, partial dentures, full dentures||80% of Delta dentist’s fee (subject to a maximum allowance)|
|Orthodontic Benefits* - for adults and dependent children||80% of Delta dentist’s fee (subject to a $2,000 lifetime maximum per person)|
*Please refer to your Evidence of Coverage contained within your separate Delta Dental benefit booklet for limitations on these benefits. Some examples of limitations on services are the number of cleanings and oral exams covered in a calendar year, and time limitations on filling and crown replacements.