|
Plan name: |
Delta Dental Gold PPO |
|
Plan year: |
2021 |
|
Group number: |
00655 |
|
Carrier: |
Delta Dental Insurance Company |
Disclaimer: Every effort has been made to ensure that the information in this summary is accurate; however no warranty of complete accuracy is made. If a discrepancy is found between this summary and the benefits you selected or the Summary Plan Description (SPD), your selections and the provisions of the SPD will govern.
| Gold Dental PPO | ||
| In-Network | Out-Of-Network | |
| Calendar Year Deductible |
$50 per individual, up to $150 per family (combined with out-of- network) |
$50 per individual, up to $150 per family (combined with out-of- network) |
| Annual Plan Maximum | $1,750 (combined with out-of-network) | $1,750 (combined with out-of-network) |
| Diagnostic and Preventive | No charge | No charge |
|
Basic Services Fillings Root Canals Periodontitis Treatment |
You pay 20% after deductible You pay 20% after deductible You pay 20% after deductible |
You pay 20% after deductible You pay 20% after deductible You pay 20% after deductible |
| Major Services | You pay 50% after deductible | You pay 50% after deductible |
|
Orthodontic Services Cost Share Lifetime Maximum Who’s Covered |
Not covered | Not covered |
Disclaimer: Every effort has been made to ensure that the information in this summary is accurate; however no warranty of complete accuracy is made. If a discrepancy is found between this summary and the benefits you selected or the Summary Plan Description (SPD), your selections and the provisions of the SPD will govern.
|
Employee Rates (monthly) |
Rate |
|
Employee Only |
$8.00
|
|
Employee + 1 |
$24.00 |
|
Employee + Child(ren) |
$24.00 |
|
Family |
$36.00 |
Disclaimer: Every effort has been made to ensure that the information in this summary is accurate; however no warranty of complete accuracy is made. If a discrepancy is found between this summary and the benefits you selected or the Summary Plan Description (SPD), your selections and the provisions of the SPD will govern.
Disclaimer: Every effort has been made to ensure that the information in this summary is accurate; however no warranty of complete accuracy is made. If a discrepancy is found between this summary and the benefits you selected or the Summary Plan Description (SPD), your selections and the provisions of the SPD will govern.
Disclaimer: Every effort has been made to ensure that the information in this summary is accurate; however no warranty of complete accuracy is made. If a discrepancy is found between this summary and the benefits you selected or the Summary Plan Description (SPD), your selections and the provisions of the SPD will govern.
|
Title/Department: |
Delta Dental Member Services |
|
Phone: |
800-765-6003 |
|
URL: |
Disclaimer: Every effort has been made to ensure that the information in this summary is accurate; however no warranty of complete accuracy is made. If a discrepancy is found between this summary and the benefits you selected or the Summary Plan Description (SPD), your selections and the provisions of the SPD will govern.