Dental Plan Availability and Comparison

Dental Plan Comparison

For all of the dental plans, the annual maximum benefit is $2,000 per person per calendar year, and the lifetime orthodontic maximum is $2,800 per dependent. You can find the detail of what is covered in each category below the chart.

Plan	DELTA DENTAL PPO	DELTA DENTAL PREMIER
Diagnostic and Preventive Care	In-network: 100% coverage Out-of-network: None	In-network: 100% coverage Out-of-network: 50% of allowed amount
Basic Restorative Care	In-network: Anterior resin restorations paid at 80%. Posterior resin restorations (white fillings on back teeth) paid as an amalgam. Out-of-network: None	In-network: 80% coverage Out-of-network: After $125 annual deductible, 50% of Allowed Amount coverage.
Major Restorative Care	In-network: 50% coverage Out-of-network: None	In-network: 50% coverage Out-of-network: No coverage
Emergency Services	In-network: Services provided same as any service. Out-of-network: Services apply $50 deductible, then same as any in-network service.	In-network: Emergency dental services provided same as eligible dental services. Out-of-network: After $125 annual deductible, emergency dental services provided same as eligible out-of-network services.
Orthodontics	In-network: 80% coverage Out-of-network: None	In-network: 80% coverage Out-of-network: 50% of allowed amount coverage

Plan

DELTA DENTAL PPO

DELTA DENTAL PREMIER

Diagnostic and
Preventive Care

In-network: 100% coverage

Out-of-network: None

In-network: 100% coverage

Out-of-network: 50% of allowed amount

Basic
Restorative Care

In-network: Anterior resin restorations paid at 80%. Posterior resin restorations (white fillings on back teeth) paid as an amalgam.

Out-of-network: None

In-network: 80% coverage

Out-of-network: After $125 annual deductible, 50% of Allowed Amount coverage.

Major
Restorative Care

In-network: 50% coverage

Out-of-network: None

In-network: 50% coverage

Out-of-network: No coverage

Emergency Services

In-network: Services provided same as any service.

Out-of-network: Services apply $50 deductible, then same as any in-network service.

In-network: Emergency dental services provided same as eligible dental services.

Out-of-network: After $125 annual deductible, emergency dental services provided same as eligible out-of-network services.

Orthodontics

In-network: 80% coverage

Out-of-network: None

In-network: 80% coverage

Out-of-network: 50% of allowed amount coverage

*Out-of-network Providers (Delta Premier only): Reimbursement is based on 50% of the Allowed Amount

If you use an out-of-network provider, you will receive significantly lower reimbursement amounts for services compared to the reimbursements you would receive from a Delta Dental in-network provider. It is strongly encouraged that your provider submit a pre-treatment estimate prior to services being received. This will prevent any surprise charges after treatment has been received. If you receive services from an out-of-network provider, you may need to:

Pay for services up-front
Pay more money for services than you would with an in-network dentist
File the dental claim form with Delta Dental
Receive reimbursements sent directly to you from Delta Dental

Need help? Find answers to your questions with these frequently asked questions from Delta Dental.

Compare in-network versus out-of-network costs on Delta Dental's cost example, Two Networks, More Choices (pdf).

What Is Covered Under Each Type of Service?

Diagnostic and Preventive Care

Oral examinations and dental cleanings
- Two oral exams and cleanings per person per calendar year
- X-rays
- Special periodontics care
- Topical fluoride to age 19
- Space maintainers

Basic Restorative Care

Fillings (customary restorative materials) is based on plan:
- Back teeth
  - Amalgam (silver) fillings: Delta Dental PPO
  - Composite (white) fillings: Delta Dental Premier
- Front teeth
  - Composite (white) fillings: Delta Dental PPO and Premier
Sealants to age 19
Extractions and other oral surgery
Periodontics (gum disease therapy)
Endodontics (root canal therapy)
Restorative crowns
Inlays and onlays
Repair of a crown

Major Restorative Care

Fixed or removable bridgework
Implants as alternative treatment
Full or partial dentures
Denture relines or rebases

Orthodontics Coverage

Limited to dependents up to age 19
Separate $2,800 lifetime maximum per covered dependent that does not start over if you change plans