Board Of Aldermen - Agenda - 4/11/2022 - P118
APPENDIX |
DELTA DENTAL PREMIER NETWORK
Group #127 Sublocations #4633 (Teachers) and #5182 (Retirees)
Coverage A
Diagnostic/Preventive
Coverage B
Basic Restorative
Coverage C
Major Restorative
Coverage D
Orthodontics
Deductible: $0 There is no deductible on your program
Covered at 100%*
Covered at 85%*
Covered at 70%*
Covered at 50%*
Diagnostic: Basic Restorative: Major Restorative: Orthodontics:
Evaluations — two in a 12- | Amalgam (silver) fillings | Removable and_ fixed | Correction of crooked
month period Composite (white) fillings | partial dentures (bridge); | teeth for dependent
(anterior teeth only) complete dentures children to age 19
X-rays (complete series or
panoramic film) once in a | Oral Surgery: Rebase and reline
3-year period; bitewing x- | Surgical and routine | (dentures)
rays once in a 12-month | extractions
period; x-rays of individual Crowns
teeth as needed Endodontics:
Root canal therapy Onlays
Oral cancer screening —
once ina 12-month period | Periodontics: Implants
Periodontal maintenance
Preventive: (cleaning)
Cleanings — four in a 12- | Four cleanings are
month period (routine | covered in a 12-month
and/or periodontal, in any | period; this can be routine
combination) and/or periodontal, in any
combination.
Fluoride twice in a 12-
month period to age 19 Treatment of gum disease
Clinical crown lengthening
Space maintainers to age | — once per lifetime per site
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Denture Repair:
Sealant application to | Repair of a removable
permanent molars, once in | denture to its original
a 3-year period per tooth, | condition
for children to age 19
Emergency Palliative
Treatment
Contract Year Maximum: $2,000 per person (Coverage A, B, and C combined) | Orthodontic Lifetime
beginning each September 1st** Maximum: $2,000 per
Age Maximum: Coverage for children up to age 26, except as noted above. person
*Benefit percentages shown are based upon the actual charge submitted to a maximum of the approved fees, or
Delta Dental’s allowance for non-participating dentists.
**Open enrollment effective date: October ‘st.
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