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deltadentalma.com

Dental Plan

Dental care is an essential part of your overall health. You have the choice between two dental
plans through Delta Dental. The Basic plan offers comprehensive coverage with lower premiums
and the Buy-Up plan provides enhanced coverage with higher premiums.
Dental Coverage

Basic Plan Buy-Up Plan
Annual Deductible $50 single / $150 family $50 single / $150 family

Annual Maximum Benefit Per Person
Applies to basic & major treatments only $1,000 $1,500
Preventive Care* Plan pays 100% no deductible Plan pays 100% no deductible
Routine cleanings, x-rays, exams
PHYSICAL WELL-BEING Crowns, bridges, dentures, oral surgery Plan pays 80% after deductible Plan pays 100% after deductible
2 per calendar year
Basic Services
Fillings & basic restorations

Major Treatment
Plan pays 60% after deductible
Plan pays 50% after deductible
& occlusal nightguards
Orthodontia Care
For dependent children to age 19
$1,500
$1,000
Lifetime Orthodontia Maximum Plan pays 50% after deductible Plan pays 50% after deductible
*To encourage dental health, both plans include two preventive care visits per year and do not count towards the annual benefit maximum.

Do you know what network your dentist is in?

Delta has two networks of providers you can choose from: the Delta Dental PPO network and the Delta Dental Premier
network. Save money on dental costs by using a dentist in the PPO network. The PPO network provides lower allowable
charges for providers and deeper discounts on certain out-of-pocket expenses.
The example below illustrates the possible savings for a porcelain crown and assumes the deductible has been met.

PPO Premier Out-of-Network
Network
Dentist Dentist Dentist
Dentist Fee $1,288 $1,288 $1,288

Maximum Dentist Can Charge $928 $1,094 $1,288
Benefit Coverage Percentage 50% 50% 50%

Member Pays $464 $547 $644

To find a participating dentist visit deltadentalma.com.

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