Stampin' Up!

Providers

You may select a dentist in either the PPO or Premier networks. Although dentists in both networks agree to accept a reduced fee for services, dentists in the PPO network agree to a lower fee than dentists in the Premier network. This means you will usually pay the lowest amount for services when you visit a dentist in the PPO network. The following chart shows an example of how this works:

Delta Dental PPO Dentists

Dentist bills

$180.00

Dentist accepts as payment in full

$90.00 (Delta Dental's agreed upon fee)

Delta Dental's payment at 50%

$45.00

Patient share

$45.00

Delta Dental Premier Dentists

Dentist bills

$180.00

Dentist accepts as payment in full

$130.00 (Delta Dental's agreed upon fee)

Delta Dental's payment at 50%

$65.00

Patient share

$65.00

Employee Premiums

Single (Per Pay Period)

$6.25

Two-Party (Per Pay Period)

$9.00

Family (Per Pay Period)

$16.25

Plan Information

Deductible:

Deductible of $50 per person with a family limit of $150 regardless of the number of patients in the family per calendar year.

Maximums:

There is an annual maximum benefit of $2,000 per person for services provided in a calendar year. There is also a separate lifetime maximum of $2,000 per patient for orthodontics.

Payment Schedule:

Benefits and covered services

Subject to deductible

In-network payment schedule

out-of-network payment schedule

Diagnostic and Preventive Benefits*: Oral examinations, routine cleanings, x-rays, fluoride treatment for children, space maintainers

100%

100% UCR**

Basic Benefits: Fillings, sealants, denture repairs, endodontics (root canals), periodontics (gum treatment)

Yes

80%

80% UCR

Oral Surgery: Incisions, excisions, surgical removal of tooth

Yes

80%

80% UCR

Major Benefits: Crowns, inlays, onlays, cast restorations, bridges, dentures, implants

Yes

50%

50% UCR

Orthodontic Benefits: Adults and dependent children

50% (up to lifetime maximum)

50% UCR (up to lifetime maximum)

Benefits and covered services

Diagnostic and Preventive Benefits*:

Oral examinations, routine cleanings, x-rays, fluoride treatment for children, space maintainers

Subject to Deductible: No
In-Network Payment Schedule: 100%
Out-of-Network Payment Schedule: 100% UCR

Basic Benefits

Fillings, sealants, denture repairs, endodontics (root canals), periodontics (gum treatment)

Subject to Deductible: Yes
In-Network Payment Schedule: 80%
Out-of-Network Payment Schedule: 80% UCR

Oral Surgery

Incisions, excisions, surgical removal of tooth

Subject to Deductible: Yes
In-Network Payment Schedule: 80%
Out-of-Network Payment Schedule: 80% UCR

Major Benefits

Crowns, inlays, onlays, cast restorations, bridges, dentures, implants

Subject to Deductible: Yes
In-Network Payment Schedule: 50%
Out-of-Network Payment Schedule: 50% UCR

Orthodontic Benefits

Adults and dependent children

Subject to Deductible: No
In-Network Payment Schedule: 50% (up to lifetime maximum)
Out-of-Network Payment Schedule: 50% UCR (up to lifetime maximum)

* Limited to twice in 12-month calendar period.
**Usual, Customary, and Reasonable. You are responsible for the difference between the charged amount and the allowed (UCR) amount.

Dental

Providers

Delta Dental PPO Dentists

Delta Dental Premier Dentists

Employee Premiums

Employee Premiums

Plan Information

Deductible:

Maximums:

Payment Schedule:

Benefits and covered services

Subject to deductible

In-network payment schedule

out-of-network payment schedule

Benefits and covered services

Resources

Delta Dental SPD

Web and Mobile Resources

Dental Benefit Summary

Delta Dental- Where's My ID Card

Delta Dental LifePerks