Your Dental Benefits
Provider: Delta Dental of Pennsylvania
Group Number: 12332 (High Option)
Group Number: 12331 (Middle Option),
Group Number: 12330 (Standard Option)
Customer Service Number: (800) 932-0783
Website: www.deltadentalins.com
| Dental Benefit | HIGH OPTION | MIDDLE OPTION | STANDARD OPTION |
|---|---|---|---|
| Deductibles – each Calendar year | $25 per person $75 per family | $50 per person $150 per family | $75 per person $225 per family |
| Maximums – each Calendar year | $2,000 per person | $1,000 per person | $750 per person |
| Benefits and Covered Services* | |||
| Diagnostic & Preventive Services (D & P) | 100% | 100% | 100% |
| Basic Services | 80% | 80% | 80% |
| Endodontics (root canals) | 80% | 80% | 80% |
| Periodontics (gum treatment) | 50% | 50% | 50% |
| Oral Surgery | 80% | 80% | 80% |
| Major Services | 50% | 50% | 50% |
| Prosthodontics (Bridges & Dentures) | 50% | 50% | 50% |
| Orthodontic Benefits* – (dependent children) | 50% | N/A | N/A |
| Orthodontic Maximums – Lifetime per covered person | $2,000 | N/A | N/A |
| * The deductible is waived for Class I and Class IV services. | |||
| ** Eligibility for Orthodontia coverage is limited to dependents to age 19. | |||
| Examples of services: | |||
| Basic Services – Fillings, simple tooth extractions, palliative treatment | |||
| Major Services – Crowns, inlays, onlays and cast restorations | |||
| * Limitations or waiting periods may apply for some benefits; some services may be excluded from your plan. Reimbursement is based on Delta Dental maximum contract allowances and not necessarily each dentist’s submitted fees. | |||
| This summary is a general outline. Please refer to the policy contract and benefit booklet for exact details and limitations. |