Dental

Benefit	Delta Dental Base Plan	Delta Dental High Plan
	In-network	In-network
Annual maximum benefit	$1,000 per person *	$1,500 per person *
Deductible (Single/Family)	$50/$150	$50/$150
Diagnostic/preventive services *	100%	100%
Basic benefit services	80%	80%
Major benefit services **	50%	80%
Orthodontia (child and adult)	No coverage	80%
Lifetime orthodontia maximum	n/a	$1,000

* Preventive and diagnostic services don’t count toward the annual maximum.
** Benefit limits on full replacement of existing dentures or crowns apply.

How are orthodontic claims paid?

• Delta Dental Base Plan: No orthodontic coverage.
• Delta Dental High Plan: The first payment is 50% of the total amount payable. The remaining 50% is paid 12 months later. Allowances for orthodontic procedures include all appliances, adjustments, insertion, removal and post treatment stabilization (retention). Calculations are based on the all-inclusive total treatment plan amount (subject to any deductible), the appropriate payment percentage and maximum amount.

Delta Dental monthly premiums

Coverage	Base Plan	High Plan
Employee Only	$31.98	$39.52
Employee + Spouse	$63.96	$79.00
Employee + Child(ren)	$60.74	$75.08
Family	$102.32	$126.46

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