Annual Deductible (applies to Basic and Major Services Only): $50/person; $150/family
Annual Maximum: $1,500/person
Enhanced Benefits Program: Your plan provides additional cleanings and/or applications of topical fluoride to people with specific health conditions that put them at risk for oral health disease. The costs of the additional cleanings and fluoride treatments will be applied to your annual maximum.
Coverage: Preventive & diagnostics covered at 100%, including:
- Routine Exams and Bite-wing X-rays (2 per benefit year. 1 per 6 months for dependent children under 19 years of age);
- Full Mouth X-rays (1 per 3 years);
- Topical Fluoride (up to 19 years of age – 1 per benefit year)
Basic Restorative Services covered at 90% in network – 80% out of network, including:
- Fillings
- Sealants for dependents up to age 16
- Space Maintainers for dependents up to age 14
- Emergency palliative treatment, Injections of Antibiotic Drugs
Major restorative services covered at 60% in network – 50% out of network.
- Major Services Include:
- Extractions
- Oral Surgery
- Endodontics
- Periodontics
- Anesthesia consultations
- Relining and Rebasing Bridges and dentures
- Crowns
- Inlays
- Veneers
- Implants
Orthodontia – $1,000/dependent
Find an In-Network Provider
Employee Monthly Premiums:
| Coverage Tier | Monthly Premium |
| Individual Coverage | $46.41 |
| Employee + Spouse | $92.82 |
| Employee + Child(ren) | $106.51 |
| Family Coverage | $156.30 |
Visit: www.deltadentalil.com
