Page 12 - 2020 McLennan County Benefits Enrollment Guide

Eligibility Primary enrollee, spouse and eligible dependent children to age 26.
Deductibles
Note: The deductibles for the Delta Dental plan Deductibles waived for Diagnostic & Preventive (D&P) and
Orthodontics? Yes.
reset at the start of the calendar year, January
1st. $50.00 per person/$150.00 per family each plan year.
Maximums
D&P counts toward maximum $1,000.00 per person each plan year
Basic Benefits – None; Major Benefits – 12 Months; Prosthodontics
Waiting Periods – 12 Months; Orthodontics – 12 Months

Benefits & Covered Services Delta Dental PPO Non-Delta Dental PPO
Dentists** Dentists**
100% 100%
Diagnostic & Preventive Services (D&P)
Exams, cleanings and x-rays
80% 80%
Basic Services
Fillings, simple tooth extractions and sealants
80% 80%
Endodontics (root canals)
80% 80%
Periodontics (gum treatment)
80% 80%
Oral Surgery
50% 50%
Major Services
Crowns, inlays, onlays and cast restorations
50% 50%
Prosthodontics
Bridges and dentures
50% 50%
Orthodontic Benefits
Dependent Children
$1,000 Lifetime $1,000 Lifetime
Orthodontic Maximums
Notes:
*Limitations or waiting periods may apply for some benefits; some services may be excluded from your plan.
Reimbursement is based on Delta Dental maximum contract allowances and not necessarily each dentist’s submitted
fees.
**Reimbursements are based on DPO contracted fees for DPO dentists, Premier contracted fees for Premier dentists
and 90 percentile for non-Delta Dental dentists. Thus, you could pay the difference plus the % of the fee.
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Delta Dental Insurance Customer Service: Claims Address:
Company 800-521-2651 or P.O. Box 1809
1130 Sanctuary Parkway, www.deltadentalins.com Alpharetta, GA 30023-1809
Suite 600 Group # 11252
Alpharetta, GA 30009

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