Dental COVERAGE OPTIONS: IN-NETWORK BENEFITS
$2,500 Maximum With Orthodontia
Contribution Amount: $
Note: If applicable, the current contribution amount you pay each pay period is on MyBenefits Online
Annual Deductible: $50 individual (up to $150 family limit)
Annual Benefits Maximum: $2,500 per person
Preventive Care―Includes routine exams, cleanings, sealants up to age 19, and other preventive/diagnostic services: Covered 100% (deductible doesn’t apply)
Basic Services―Includes fillings: You pay 10% after deductible
Major Services―Includes crowns, bridges, and onlays: You pay 40% after deductible
Orthodontia: You pay 50% (no deductible) Note: $2,500 lifetime maximum benefit per person—adult and child
$1,000 Maximum Without Orthodontia
Contribution Amount: $
Note: If applicable, the current contribution amount you pay each pay period is on MyBenefits Online
Annual Deductible: $50 individual (up to $150 family limit)
Annual Benefits Maximum: $1,000 per person
Preventive Care―Includes routine exams, cleanings, sealants up to age 19, and other preventive/diagnostic services: Covered 100% (deductible doesn’t apply)
Basic Services―Includes fillings: You pay 20% after deductible
Major Services―Includes crowns, bridges, and onlays: You pay 50% after deductible
Orthodontia: Not covered
Coverage Option
$2,500 Maximum With Orthodontia
$1,000 Maximum Without Orthodontia
Contribution Amount
$
$
Note: If applicable, the current contribution amount you pay is on MyBenefits Online
Annual Benefits Maximum
$2,500 per person
$1,000 per person
Annual Deductible
◄ $50 individual (up to $150 family limit) ►
Preventive Care Includes routine exams, cleanings, sealants up to age 19, and other preventive/diagnostic services
◄ Covered 100% (deductible doesn't apply) ►
Basic Services Includes fillings
You pay 10% after deductible
You pay 20% after deductible
Major Services Includes crowns, bridges, and onlays
You pay 40% after deductible
You pay 50% after deductible
Orthodontia
You pay 50% (no deductible) Note: $2,500 lifetime maximum benefit per person—adult and child
Not covered
Note: For services over $200, you’re encouraged to obtain prior authorization, even though it’s not required.
Save money with a Delta Dental preferred provider
Network providers offer services at a discount, plus conveniently submit claims on your behalf. You can use out-of-network providers if you wish under either coverage option, but your out-of-pocket costs may be higher. In addition, you may be responsible for filing your own claims.