HomeMy WebLinkAboutDelta Dental Benefits 2012- Summary Sheet
SUMMARY OF DENTAL BENEFITS
After you have satisfied the deductible, if any, your dental program pays the following
percentages of the treatment cost, up to a maximum fee per procedure. The maximum fee
allowed by Delta Dental is different for participating dentists and nonparticipating dentists. If you
see a nonparticipating dentist, your out-of-pocket expenses may increase.
Diagnostic and Preventive Services .............................. 100%
Basic Services .................................................................. 80%
Endodontics ..................................................................... 80%
Periodontics ..................................................................... 80%
Oral Surgery ..................................................................... 80%
Major Restorative Services .............................................. 50%
Prosthetic Repairs and Adjustments ................................ 50%
Prosthetics ....................................................................... 50%
Benefit Maximums
The Program pays up to a maximum of $1,000.00 for each Covered Person per Coverage Year
subject to the coverage percentages identified above. Benefit Maximums may not be carried over
to future coverage years.
Deductible
There is a $25.00 deductible per Covered Person each Coverage Year not to exceed three (3)
times that amount ($75.00) per Family Unit.
The deductible does not apply to Diagnostic and Preventive Services.
Coverage Year
A Coverage Year is a 12-month period in which deductibles and benefit maximums apply. Your
Coverage Year is JANUARY to JANUARY.
Comprehensive Standard 04/2003