Page 14 - 2020 Intertek Benefits Enrollment
P. 14
Dental
Dental Coverage with Delta Dental
Choose a Delta Dental PPO dentist to ensure you receive the deepest
discounts. Choose a Delta Premier dentist and receive discounts,
although they may not be as deep as the PPO network. If you receive
care outside of Delta’s PPO or Premier network you will likely pay a
greater amount for dental care and the provider may balance bill you.
To ind a Delta Dental network provider in your area go to
deltadentalins.com or call 800.521.2651.
Delta Network Out-of-Network
Deductible/Maximum
Individual deductible $50 $50
Family deductible $150 $150
Calendar year maximum $1,500 $1,500
Coinsurance
Preventive services 100% no deductible 100% no deductible
(Exams, x-rays, cleanings)
Basic services 80% after deductible 80% after deductible
(Fillings, root canals, oral surgery)
Major services 50% after deductible 50% after deductible
(Bridges, crowns, dentures)
Orthodontia
Coinsurance 50% 50%
Lifetime maximum $1,500 $1,500
Eligibility Dependent children to age 26
Your cost of coverage is summarized when you enroll online through
https://my.adp.com.
14 2020 Benefits Guide
Dental Coverage with Delta Dental
Choose a Delta Dental PPO dentist to ensure you receive the deepest
discounts. Choose a Delta Premier dentist and receive discounts,
although they may not be as deep as the PPO network. If you receive
care outside of Delta’s PPO or Premier network you will likely pay a
greater amount for dental care and the provider may balance bill you.
To ind a Delta Dental network provider in your area go to
deltadentalins.com or call 800.521.2651.
Delta Network Out-of-Network
Deductible/Maximum
Individual deductible $50 $50
Family deductible $150 $150
Calendar year maximum $1,500 $1,500
Coinsurance
Preventive services 100% no deductible 100% no deductible
(Exams, x-rays, cleanings)
Basic services 80% after deductible 80% after deductible
(Fillings, root canals, oral surgery)
Major services 50% after deductible 50% after deductible
(Bridges, crowns, dentures)
Orthodontia
Coinsurance 50% 50%
Lifetime maximum $1,500 $1,500
Eligibility Dependent children to age 26
Your cost of coverage is summarized when you enroll online through
https://my.adp.com.
14 2020 Benefits Guide
