Page 20 - AESC 2019 Benefits Gudie

Dental Plan Details

Delta Dental PPO Provider
In-Network Delta Premier and
Non-Participating Providers
Calendar Year Deductible $30 per person $30 per person
Calendar Year Maximum $1,500—does not apply to preventive* $1,500—does not apply to preventive*
Coinsurance
Preventive 100% no deductible 100% no deductible
Basic 80% after deductible 60% after deductible
Major 60% after deductible 50% after deductible
Orthodontia
Coinsurance 80% no deductible 60% no deductible
Lifetime Maximum $2,000 per person $2,000 per person
Benefit Applies to Adults and Children Adults and Children
Visits and Exams
Visit for Oral Examination 100% no deductible $25 copay
Limitations 2 × per calendar year
Prophylaxis, Including Scaling and 100% no deductible $25 copay
Polishing
Space Maintainers 100% no deductible 100% no deductible
Fluoride 100% no deductible $25 copay
Limitations 2 × per calendar year to age 15
Sealants 90% after deductible 70% after deductible
Limitations One per tooth to age 15
X-Rays
Bitewing X-Rays 100% no deductible 100% no deductible
Limitations 1 × per calendar year to age 12; 1 × per 18 mos . ages 12–18;
1 × per 24 months ages 18+
Full Mouth X-Rays 100% no deductible 100% no deductible
Limitations 1 × per 36 months
Endodontics
Root Canals 80% after deductible 60% after deductible
Basic Services/Minor Restorations
Fillings 80% after deductible 60% after deductible
Oral Surgery 80% after deductible 60% after deductible
Periodontics
Treatment of Gum Disease 80% after deductible 60% after deductible
Prosthodontics/Major Restorations
Bridges 60% after deductible 50% after deductible
Crowns 60% after deductible 50% after deductible
Dentures 60% after deductible 50% after deductible
Implants 60% after deductible 50% after deductible

* Preventive services do not apply toward, nor take away from, your annual maximum benefit

20 2019 Benefits Enrollment