2021 Delta Dental Platinum PPO

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Plan name:	Delta Dental Platinum PPO
Plan year:	2022
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.

	Platinum Dental PPO
	In-Network	Out-Of-Network
Calendar Year Deductible	$25 per individual, up to $75 per family (combined with out-of- network)	$25 per individual, up to $75 per family (combined with in-network)
Annual Plan Maximum	$2,500 (combined with out-of-network)	$2,500 (combined with in-network)
Diagnostic and Preventive	No charge	No charge
Basic Services Fillings Root Canals Periodontitis Treatment	You pay 10% after deductible You pay 10% after deductible You pay 10% after deductible	You pay 10% after deductible You pay 10% after deductible You pay 10% after deductible
Major Services	You pay 40% after deductible	You pay 40% after deductible
Orthodontic Services Cost Share Lifetime Maximum Who’s Covered	You pay 50% Deductible waived $2,500 (combined with out-of-network) Dependent children and adults	You pay 50% Deductible waived $2,500 (combined with out-of-network) Dependent children and adults

Delta Dental PPO Benefit Summary

Employee Rates (monthly)	Rate
Employee Only	$16.00
Employee + 1	$40.00
Employee + Child(ren)	$40.00
Family	$62.00

Find a Provider

Delta Dental Claim Form

Title/Department:	Delta Dental Member Services
Phone:	800-765-6003
URL:	https://www.deltadentalins.com/