| Benefit Summary * |
| Level 2 (5-99 lives) |
| ( in effect on 11/3/2002 ) |
| |
|
|
| |
In Network |
Out of Network |
| General |
|
|
| Deductible |
$50 per person/year |
$50 per person/year |
| Maximum |
$1,500 |
$1,500 combined with in network |
| Waiting Period |
None |
None |
| |
|
|
| Diagnostic |
|
|
| Office Visit |
Oral exam/office visit 2/yr. at 100% if dentist has fee
filed with Delta. |
100% of the DPO fee Schedule |
| X-rays - complete set |
100% - full set covered once every 5 years, bitewings 2/yr
to age 18; 1/yr for 18+ |
100% of the DPO fee Schedule |
| |
|
|
| Preventive |
|
|
| Prophylaxis |
100% not subject to the deductible; limited to two in a
calendar year |
100% of the DPO fee Schedule |
| Space maintainer |
100% |
100% of the DPO fee Schedule |
| |
|
|
| Restorative |
|
|
| Amalgam - primary |
80% after deductible |
80% of the DPO fee Schedule |
| Amalgam - permanent |
80% after deductible |
80% of the DPO fee Schedule |
| |
|
|
| Endodontics |
|
|
| Root canal - anterior |
80% after deductible |
80% of the DPO fee Schedule |
| Root canal - molar |
80% after deductible |
80% of the DPO fee Schedule |
| |
|
|
| Periodontics |
|
|
| Gingivectomy - per quadrant |
80% after deductible |
80% of the DPO fee Schedule |
| Periodontal scaling - per quadrant |
80% after deductible |
80% of the DPO fee Schedule |
| |
|
|
| Oral Surgery |
|
|
| Extraction - single tooth |
80% after deductible |
80% of the DPO fee Schedule |
| Extraction impacted |
80% after deductible |
80% of the DPO fee Schedule |
| |
|
|
| Adjunctive |
|
|
| Local anesthesia |
80% after deductible |
80% of the DPO fee Schedule |
| Broken appt. fee |
At the dentists discretion |
At the dentists discretion |
| General anesthesia |
Covered at 80% for oral surgery procedures |
Covered at 80% of the DPO fee Schedule for oral surgery |
| |
|
|
| Crown/Bridge |
|
|
| Porcelain/Ceramic |
50% after deductible |
50% of the DPO fee Schedule |
| Inlay - metallic 1 surface |
50% after deductible |
50% of the DPO fee Schedule |
| |
|
|
| Prosthodontics |
|
|
| Upper or lower partial |
50% after deductible |
50% of the DPO fee Schedule |
| Upper or lower complete |
50% after deductible |
50% of the DPO fee Schedule |
| |
|
|
| Orthodontics |
|
|
| Plan, x rays, study model |
50% optional orthodontic benefits for dependents to age
19 (dependents age 19-23 covered if full-time student). $1000
lifetime max. per patient. Available for groups of 25+ enrollees |
50% optional orthodontic benefits for dependents to age
19 (dependents age 19-23 covered if full-time student). $1000
lifetime max. per patient. Available for groups of 25+ enrollees |
| Limited treatment |
N/A |
N/A |
| Full treatment |
50% optional orthodontic benefits for dependents to age
19 (dependents age 19-23 covered if full-time students). $1000
lifetime max. per patient. Available for groups of 25+ enrollees |
50% optional orthodontic benefits for dependents to age
19 (dependents age 19-23 covered if full-time students). $1000
lifetime max. per patient. Available for groups of 25+ enrollees |
| |
|
|
| Notes: |
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| * Please refer to certificate for full benefit
descriptions and limitations |
