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Summary Plan Description (SPD)
IBEW-NECA DELTA DENTAL PPO PLAN Summary of Dental Benefits Delta’s payment is always based on Delta’s allowance under their PPO plan. |
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In-Network |
Out-of-Network |
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Benefits |
Delta Pays |
You Pay |
Delta Pays |
After Any Applicable Deductible, You Pay |
Diagnostic/Preventive |
100% |
Nothing |
100% |
Balance in excess of Delta’s allowance |
Basic (Fillings, Sealants, Oral Surgery, Root Canals) |
95% |
5% |
80% |
20% + Balance in excess of Delta’s allowance |
Major (Crowns & Casts, Dentures, Bridges, Implants) |
75% |
25% |
50% |
50% + Balance in excess of Delta’s allowance |
Orthodontics - Child |
50% |
50% |
50% |
50% + Balance in excess of Delta’s allowance |
Lifetime Ortho Max |
$1,400 |
$1,400 |
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Deductible |
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Per patient/calendar year |
None |
$25 |
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Per family/calendar year |
None |
$75 |
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Deductible waived for diagnostic & preventive services |
Not Applicable |
Yes |
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Maximum Benefit |
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Per patient/calendar year |
$2,500 |
$2,000 |
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Maximum waived for Diagnostic/Preventive services |
Yes |
Yes |
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