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2021 Delta Dental Platinum PPO
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2021 Delta Dental Gold PPO
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In-Network |
Out-of-Network
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In-Network
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Out-of-Network
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Basic Information |
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Annual Deductible |
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Individual |
$25 |
$25 | $50 | $50 |
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Family |
$25 per individual, up to $75 per family |
$25 per individual, up to $75 per family | $50 per individual, up to $150 per family | $50 per individual, up to $150 per family |
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Waived for Preventive |
Yes |
Yes | Yes | Yes |
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Annual Plan Maximum |
$2,500 (combined with out-of-network) |
$2,500 (combined with out-of-network) | $1,750 (combined with out-of-network) | $1,750 (combined with out-of-network) |
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Plan Accumulation |
Calendar Year |
Calendar Year | Calendar Year | Calendar Year |
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Non-Network Provider Reimbursement |
N/A |
Reimbursement is based on PPO contracted fees for PPO dentists, Delta Dental Premier contracted fees for Premier dentists, and the program allowance for nonDelta Dental dentists. | N/A | Reimbursement is based on PPO contracted fees for PPO dentists, Delta Dental Premier contracted fees for Premier dentists, and the program allowance for nonDelta Dental dentists. |
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Diagnostic & Preventive |
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Exams |
No charge | No charge | No charge | No charge |
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Cleanings |
No charge | No charge | No charge | No charge |
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Fluoride Treatment |
No charge | No charge | No charge | No charge |
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Space Maintainers |
10% after deductible | 10% after deductible | 10% after deductible | 10% after deductible |
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Bitewing X-Rays |
No charge | No charge | No charge | No charge |
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Diagnostic X-Rays |
No charge | No charge | No charge | No charge |
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Sealants |
10% after deductible | 10% after deductible | 10% after deductible | 10% after deductible |
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Basic Services |
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Fillings |
10% after deductible | 10% after deductible | 20% after deductible | 20% after deductible |
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Endodontic Treatment |
10% after deductible | 10% after deductible | 20% after deductible | 20% after deductible |
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Periodontic Treatment |
10% after deductible | 10% after deductible | 20% after deductible | 20% after deductible |
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Simple Extractions |
10% after deductible | 10% after deductible | 20% after deductible | 20% after deductible |
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Oral Surgery |
10% after deductible | 10% after deductible | 20% after deductible | 20% after deductible |
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Major Services |
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Crowns, Inlays, Onlays |
40% after deductible | 40% after deductible | 50% after deductible | 50% after deductible |
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Bridges |
40% after deductible | 40% after deductible | 50% after deductible | 50% after deductible |
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Dentures |
40% after deductible | 40% after deductible | 50% after deductible | 50% after deductible |
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Orthodontic Services |
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Orthodontia |
50% deductible waived |
50% deductible waived |
Not covered | Not covered |
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Orthodontia Lifetime |
$2,500 (combined with out-of-network) |
$2,500 (combined with in-network) |
N/A | N/A |
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Dependent Children |
Dependent Children and Adults |
Dependent Children and Adults |
N/A | N/A |
