print logo
Main Content Anchor

Coverage and Costs Comparison for Certain Procedures: Preferred Provider Option (PPO) Plans

The following chart provides a comparison of costs for certain procedures covered by the state-sponsored dental plans. Please consult each dental plan's Evidence of Coverage for detailed information and plan limitations.

Comparison of Dental Plan Benefits
Type of Plan Delta Dental PPO plus Premier Basic Delta Dental PPO plus Premier Basic Delta Dental PPO plus Premier Enhanced PPO/using Participating  Provider1 PPO/using Non-Participating Provider
Who is Covered Represented Employees Dependents of Represented Employees Excluded Employees and Dependents Employees and Dependents Employees and Dependents

Diagnostic and Preventive Benefits (two cleanings annually)

 No charge2 No charge2 No charge2 No charge​2,3 20%3
Basic Benefits 10% 20% 10% 10% 20%
Crowns 20% 50% 20% 20% 50%
Bridges, Full and Partial Dentures 50% 50% 50% 40% 50%
Implants Not covered Not covered Not covered Will pay 50% up to a lifetime maximum of $2,500 Will pay 50% up to a lifetime maximum of $2,500
Orthodontia

Will pay up to 50% of approved fee for orthodontia, with a lifetime maximum for this benefit of $1,000 for employee

Will pay up to 50% of approved fee for orthodontia, with a lifetime maximum for this benefit of $1,000 for dependent

Will pay up to 50% of approved fee for orthodontia, with a lifetime maximum for this benefit of $1,000 for adults and dependent children

Will pay up to 50% of approved fee, with a lifetime maximum of $1,000 for each adult and $1,500 for dependent children

Will pay up to 50% of approved fee, with a lifetime maximum of $1,000 for each adult and dependent children
Annual Deductible $50 $50 per person $25 per person $25 per person $75 per person
Maximum Deductible $50 $150 per family $100 per family $100 per family $200 per family
Annual Maximum $2,000 $1,000 per person $2,000 per person $2,000 per person $1,000 per person
  1. Diagnostic and Preventive Benefits are exempt from the deductible.
  2. The level of benefits and covered services reflected in the chart are based on services provided by a PPO Plan dentist; for services provided by a non-PPO plan dentist, the level of benefits is lower.
  3. The PPO includes a third cleaning for high-risk patients.
  Updated: 8/16/2017
One Column Page
Link Back to Top