Dental Plan Options Chart

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Feature	Basic Plan	Premier Plan
Annual deductible (calendar-year basis)	$50 per person, but no more than $150 per family	$50 per person, but no more than $150 per family
Maximum calendar-year benefit (per covered individual)	$1,250	$2,000
PREVENTIVE AND DIAGNOSTIC CARE
Oral exams (two per calendar year)	100% with no deductible	100% with no deductible
X-rays Bitewing series (one set per calendar year) Full mouth (once every 60 months) Single (as required)	100% with no deductible	100% with no deductible
Standard cleaning (two per calendar year)	100% with no deductible	100% with no deductible
Fluoride treatment (two per calendar year under age 19)	100% with no deductible	100% with no deductible
Sealants (once every 24 months per unrestored permanent molar and bicuspid, up to age 19)	100% with no deductible	100% with no deductible
Space maintainers Unilateral space maintainers once per lifetime for lost deciduous (baby) teeth Bilateral space maintainers once every 60 months for lost deciduous (baby) teeth	100% with no deductible	100% with no deductible
Periodontal maintenances following active therapy (two per year)	100% with no deductible	100% with no deductible
TELEDENTISTRY¹
Periodic oral exam	100% with no deductible	100% with no deductible
Limited oral exam	100% with no deductible	100% with no deductible
Re-evaluation – limited problem focused, not post-op visit	100% with no deductible	100% with no deductible
Re-evaluation – post-op visit	100% with no deductible	100% with no deductible
BASIC RESTORATIVE CARE
Amalgam (silver) fillings	50% after deductible	80% after deductible
Composite (white) fillings	50% after deductible (all teeth)	80% after deductible (all teeth)
Root canal therapy	50% after deductible	80% after deductible
Guided tissue regeneration and bone replacement graft (once per every 24 months)	50% after deductible	80% after deductible
Extractions and other routine oral surgery	50% after deductible	80% after deductible
Other [consultation by a specialist; palliative treatment; general anesthesia for complex surgical procedures; occlusal guards (to treat bruxism)]	50% after deductible	80% after deductible
MAJOR RESTORATIVE CARE
Crowns, dentures, bridges (replacement limited to once every 60 months)	50% after deductible	50% after deductible
Implants (once per tooth per lifetime)	Not covered	50% after deductible
TMJ (reversible non-surgical procedures)	50% with no deductible (lifetime maximum of $1,000 per person)	50% with no deductible (lifetime maximum of $1,000 per person)
ORTHODONTICS (CHILDREN UNDER AGE 19)
Elective braces and related services for dependent children under age 19	Not covered	50% with no deductible (lifetime orthodontic maximum of $1,500 per person)²

¹ Plan deductibles, copays and time and frequency limitations apply to teledentistry exams just as they would for in-person exams.
² Benefits are paid over the course of treatment, not in a lump sum. You must be an eligible employee at the time of each payment.

NOTE: Your plan also includes coverage when using an out-of-network dentist. Plan allowances are based on the reasonable & customary charges as determined by the local Delta Dental plan. When using an out-of-network dentist, your out-of-pocket expenses may be higher. In addition to any deductible and coinsurance amounts, you will be responsible for the difference between what the plan allows and the dentist’s actual charges (if they are higher than the allowed amount).

Dental Plan Options Chart

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