Page 9 - 15NH Intertek
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Intertek U.S.A.
Dental
Dental
Our dental plan makes dental care more affordable for employees and
their families. Remember to choose an in-network dentist to ensure you’re
receiving the deepest level of discounted services.
To ind a Preferred Dental Program (PDP) participating in-network provider
in your area go to www.deltadentalins.com or call 800-521-2651.
PDP In-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
Employee Contributions
Employee $4.02
Employee + 1 $8.76
Employee + 2 + $14.73
9
Dental
Dental
Our dental plan makes dental care more affordable for employees and
their families. Remember to choose an in-network dentist to ensure you’re
receiving the deepest level of discounted services.
To ind a Preferred Dental Program (PDP) participating in-network provider
in your area go to www.deltadentalins.com or call 800-521-2651.
PDP In-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
Employee Contributions
Employee $4.02
Employee + 1 $8.76
Employee + 2 + $14.73
9
