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Dental Plan At-A-Glance

DENTAL PLAN
Angeles Contractor, Inc. offers regular, full-time employees and eligible dependents dental coverage through Delta
Dental – which features a wide network of dentists and facilities nationwide. This plan enables you to receive services
from the Delta Dental PPO network of dentists or any other licensed dentist each time you receive preventive, basic or
major dental care services. The plan covers 100% of eligible in-network expenses for preventive services. After you pay a
deductible, the plan will pay a portion of your eligible basic or major dental expenses, but you will generally receive
higher benefits if you visit a Delta Dental PPO network dentist. For a list of participating dentists in your area, refer to
the directory through www.deltadentalins.com

DELTA DENTAL PPO

Services In-Network Out-of-Network

Deductible $25 per person (In-Network), $50 per person (Out of Network)

Annual Calendar Year Maximum $1,500 $1,500
Benefit per Member

Preventive Care Plan pays 100% Plan pays 100%
(cleanings, exams, x-rays) (deductible waived) (deductible waived)

Basic Care Plan pays 80% Plan pays 80%
(fillings, root canals, oral surgery, You pay 20% You pay 20% +
endodontics, periodontics) amount over allowed amount
Major Care Plan pays 60% Plan pays 50%
(crowns, dentures, bridges) You pay 40% You pay 50% +
amount over allowed amount
Orthodontics Plan pays 50% Plan pays 50%
You pay 50% You pay 50% + amount over allowed
amount

Orthodontics Maximum $1,000 per Calendar Year
For dependent Child up to age of 19.

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