Delta PPO Plus Premier
PPO Network Coverage
Premier Network Coverage
Non-Participating Dentist Coverage
Plan Year Deductible: $50 (individual)/$150 (family)
Plan Year Maximum (per member): $1,250
Preventive and diagnostic services
100%, no deductible
80%, no deductible
80%*, no deductible
Basic restorative services (including oral surgery, white fillings,periodontics)
80%, after deductible
80%, after deductible
80%*, after deductible
Major restorative and prostheticservices
50%, after deductible
50%, after deductible
50%*, after deductible
Orthodontia (for children up to age 19)
50%, to $1,000 lifetime maximum
Not covered
Not covered
Dental paycheck costs (For the 2015/2016 plan year, effective 7/01/2015)
Delta Dental PPO Plus Premier
Weekly
Associate only
$3.03
Associate + child(ren)
$6.33
Associate + spouse
$7.26
Family
$9.90