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  Now Showing: Health Benefits Summary
 
Eligibility:

Plan I Earned, Plan I Self-Pay and Senior Performers. View SPD

Plan II Earned and Plan II Self-Pay are covered if they have 3 years of Earned Eligibility. View SPD .

Lower Cost Self-Pay participants are covered under the dental plan they were covered under when they had Earned Eligibility.

BenefitsDeltaPreferred Network DentistDeltaPremier Dentist or Non-Network Dentist

Calendar Year DeductiblePlan I: $75/person;$200/family
Plan II: $100/person;no family maximum deductible
Plan I: $75/person;$200/family
Plan II: $100/person;no family maximum deductible
 

Diagnostic & Preventive

Oral exams, cleanings, X-rays, fluoride treatments, sealants
100%; deductible waived Plan I: 75%
Plan II: 60%
 

Basic Services

Fillings, oral surgery, root canals, periodontics, general anesthesia
Plan I: 75%
Plan II: 60%
Plan I: 75%
Plan II: 60%
 

Major Services

Inlays, crowns, bridges, dentures, implants
50%50%
 

MaximumsPlan I: $2,500
Plan II: $1,000

 
   
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