| Benefit Summary * |
| Level 1 (5-99 lives)
|
| ( in effect on 11/3/2002 ) |
| |
|
| General |
|
| Deductible |
$50 per person/year (rollover credit available) |
| Maximum |
$1,500 per person |
| Waiting Period |
No waiting periods |
| |
|
| Diagnostic |
|
| Office Visit |
Oral exam/office visit 2/yr. at 100% if dentist has fee
filed with Delta. |
| X-rays - complete set |
100% - full set covered once every 5 years, bitewings 2/yr
to age 18; 1/yr for 18+ |
| |
|
| Preventive |
|
| Prophylaxis |
100% not subject to deductible |
| Space maintainer |
100% not subject to deductible |
| |
|
| Restorative |
|
| Amalgam - primary |
80% subject to deductible |
| Amalgam - permanent |
80% subject to deductible |
| |
|
| Endodontics |
|
| Root canal - anterior |
80% subject to deductible |
| Root canal - molar |
80% subject to deductible |
| |
|
| Periodontics |
|
| Gingivectomy - per quadrant |
80% subject to deductible |
| Periodontal scaling - per quadrant |
80% subject to deductible |
| |
| Oral Surgery |
| Extraction - single tooth |
80% subject to deductible |
| Extraction impacted |
80% subject to deductible |
| |
|
| Adjunctive |
|
| Local anesthesia |
80% subject to deductible |
| Broken appt. fee |
At dentists discretion |
| General anesthesia |
80% for services related to oral surgery, subject to deductible |
| |
|
| Crown/Bridge |
|
| Porcelain/Ceramic |
50% subject to deductible |
| Inlay - metallic 1 surface |
50% subject to deductible |
| |
|
| Prosthodontics |
|
| Upper or lower partial |
50% subject to deductible |
| Upper or lower complete |
50% subject to deductible |
| |
|
| Orthodontics |
|
| Plan, x rays, study model |
50% optional orthodontic benefits for dependents to age
19 (extended to age 23 for full-time students). $1000 lifetime
max. per patient. Available for groups of 25+ enrollees |
| Limited treatment |
N/A |
| Full treatment |
50% optional orthodontic benefits for dependents to age
19 (extended to age 23 for full-time students). 1000 lifetime
max. per patient. Available for groups of 25+ enrollees |
| |
|
| Notes: |
|
| * Please refer to certificate for full benefit
descriptions and limitations |
