Dental Benefits
Dental Benefits
Dental coverage includes PPO Low and PPO High plan options.
Dental Premiums
| Coverage Tier | HIGH MONTHLY | HIGH SEMI-MONTHLY | LOW MONTHLY | LOW SEMI-MONTHLY |
|---|---|---|---|---|
| Employee Only | $24.48 | $12.24 | $4.21 | $2.11 |
| Employee + Spouse | $62.58 | $31.29 | $19.80 | $9.90 |
| Employee + Child(ren) | $74.51 | $37.26 | $33.73 | $16.87 |
| Family | $102.12 | $51.06 | $49.32 | $24.66 |
Employee Only
- HIGH MONTHLY
- $24.48
- HIGH SEMI-MONTHLY
- $12.24
- LOW MONTHLY
- $4.21
- LOW SEMI-MONTHLY
- $2.11
Employee + Spouse
- HIGH MONTHLY
- $62.58
- HIGH SEMI-MONTHLY
- $31.29
- LOW MONTHLY
- $19.80
- LOW SEMI-MONTHLY
- $9.90
Employee + Child(ren)
- HIGH MONTHLY
- $74.51
- HIGH SEMI-MONTHLY
- $37.26
- LOW MONTHLY
- $33.73
- LOW SEMI-MONTHLY
- $16.87
Family
- HIGH MONTHLY
- $102.12
- HIGH SEMI-MONTHLY
- $51.06
- LOW MONTHLY
- $49.32
- LOW SEMI-MONTHLY
- $24.66
Coverage Details
| Feature | PPO LOW PLAN — In-Network | PPO LOW PLAN — Out-of-Network | PPO HIGH PLAN — In-Network | PPO HIGH PLAN — Out-of-Network |
|---|---|---|---|---|
| Calendar Year Deductible - Individual/Family | $50/$150 | $50/$150 | $50/$150 | $50/$150 |
| Calendar Year Maximum - Per Person | $1,500 | $1,500 | $2,000 | $2,000 |
| Preventive Services | 100% | 100% | 100% | 100% |
| Basic Services | 80%* | 80%* | 80%* | 80%* |
| Major Services | Not Covered | Not Covered | 50%* | 50%* |
| Orthodontics - Children only up to Age 26 | Not Covered | Not Covered | 50% | 50% |
| Orthodontic Lifetime Maximum | Not Covered | Not Covered | $2,000 per person | $2,000 per person |
Calendar Year Deductible - Individual/Family
- PPO LOW PLAN — In-Network
- $50/$150
- PPO LOW PLAN — Out-of-Network
- $50/$150
- PPO HIGH PLAN — In-Network
- $50/$150
- PPO HIGH PLAN — Out-of-Network
- $50/$150
Calendar Year Maximum - Per Person
- PPO LOW PLAN — In-Network
- $1,500
- PPO LOW PLAN — Out-of-Network
- $1,500
- PPO HIGH PLAN — In-Network
- $2,000
- PPO HIGH PLAN — Out-of-Network
- $2,000
Preventive Services
- PPO LOW PLAN — In-Network
- 100%
- PPO LOW PLAN — Out-of-Network
- 100%
- PPO HIGH PLAN — In-Network
- 100%
- PPO HIGH PLAN — Out-of-Network
- 100%
Basic Services
- PPO LOW PLAN — In-Network
- 80%*
- PPO LOW PLAN — Out-of-Network
- 80%*
- PPO HIGH PLAN — In-Network
- 80%*
- PPO HIGH PLAN — Out-of-Network
- 80%*
Major Services
- PPO LOW PLAN — In-Network
- Not Covered
- PPO LOW PLAN — Out-of-Network
- Not Covered
- PPO HIGH PLAN — In-Network
- 50%*
- PPO HIGH PLAN — Out-of-Network
- 50%*
Orthodontics - Children only up to Age 26
- PPO LOW PLAN — In-Network
- Not Covered
- PPO LOW PLAN — Out-of-Network
- Not Covered
- PPO HIGH PLAN — In-Network
- 50%
- PPO HIGH PLAN — Out-of-Network
- 50%
Orthodontic Lifetime Maximum
- PPO LOW PLAN — In-Network
- Not Covered
- PPO LOW PLAN — Out-of-Network
- Not Covered
- PPO HIGH PLAN — In-Network
- $2,000 per person
- PPO HIGH PLAN — Out-of-Network
- $2,000 per person
- *After deductible
Plan Notes
- Dental premium contributions are deducted from your paycheck on a pre-tax basis.
- If your dentist doesn't participate in your plan's network, your out-of-pocket costs will be higher and you are subject to any charges beyond the Reasonable and Customary (R&C).
- To find a network dentist, visit Delta Dental at www.deltadentalins.com.