Page 11 - MCU Benefits Enrollments Guide
P. 11
Dental Group #0629
Delta Dental Benefits
Benefit Highlights PPO Plus Premier
100% UCR
Cleanings (2 per 12 months), Oral
Type 1 Procedures: Diagnostic & Exams, Bitewing X-rays (1 per 12
Preventative Services months), Sealants (Children up to
19), Space Maintainers
80% UCR
Type 2 Procedures: Basic Services Fillings, Endodontics, Periodontics,
Simple extractions, Oral Surgery
50% UCR
Type 3 Procedures: Major Surgical Extractions, Crowns, Bridges
Services
& Implants, Dentures.
50%
Orthodontics (up to age 19) $1,000 lifetime maximum
Waiting Periods (New Hires) Waiting periods do not apply for
Late Entrant (untimely entrants) New Hires or Late Entrants
Individual: $50
Family: $150
Calendar Year Deductible Deductible applies to Basic & Major
Services
Calendar Year Maximum $1,000
Dental benefits are on a Plan Year basis from January 1 to December 31.
th
Allowable charge is 90 UCR. Please refer to Plan Documents for full coverage details.
10 | P a g e
