Securing Your Financial Future –
Entrusted since 1957

Securing Your Financial Future – Entrusted since 1957

Dental Covered Services

Covered ServicesStandard Plan2Enhanced Plan2
Maximum benefit per person per calendar year$4,000$35,000
Diagnostic and Preventive Care
• Oral exams and cleanings – twice in any 12-month period provided they are 6 months apart
• Bitewing X-rays – twice in any 12-month period
• Full mouth X-rays – once in 3-year period
• Fluoride treatments – twice in any 12-month period up to age 19
• Sealants - up to age 14
• Space maintainer - up to age 14
PPO - 100%
Premier3 - 100%
Out of Network4 - 100%
PPO - 100%
Premier3 - 100%
Out of Network4 - 100%
Basic Care
• Anterior composite “white” fillings
• Oral surgery – extractions and surgery
• Endodontics – pulpal therapy and root canal fillings
• Periodontics – treatment of gums
PPO - 50%
Premier3 - 50%
Out of Network4 - 50%
PPO - 80%
Premier3 - 60%
Out of Network4 - 60%
Major Dental Care
• Crowns, inlays5, and onlays5
• Implants – two implant annual maximum (per insured)
• Prosthodontics – construction or repair of fixed bridges, partial, or complete dentures
PPO - 35%
Premier3 - 20%
Out of Network4 - 20%
PPO - 50%
Premier3 - 40%
Out of Network4 - 40%
Orthodontics – up to age 19
(12-month waiting period in the Enhanced Plan for each dependent receiving treatment)
Not CoveredPPO - 50%
Premier3 - 50%
Out of Network4 - 50%

$2,000 per person maximum lifetime

FOR COMPARISON USE ONLY. This comparison is only a brief summary of benefits offered under each plan. Complete details, including limitations and exclusions, are detailed in the policy. In the event of discrepancies, the policy shall govern.

1Not available in Alaska.

2Delta Dental dentists accept Delta Dental’s Maximum Plan Allowances or their charged fees, whichever is less, as the full payment for services. This is known as Delta Dental’s Allowed Amount. A Maximum Plan Allowance is the amount payable for a service provided by Delta Dental dentists and non-Delta Dental dentists. It is calculated by Delta Dental from claim charges submitted on a regional basis for a given service by dentists of similar training within the same geographical area. Delta Dental blends the claim charges with dentist fee information from a number of other sources, including dentist fee filings, using various factors, subject to regulatory limitations and adjustment for extreme difficulty or unusual circumstances. The dollar amount of the Maximum Plan Allowance for services may be different depending upon the network in which the dentist participates. Plus, dentists who do not participate in Delta Dental’s networks (non-Delta Dental dentists) may not accept Delta Dental’s reimbursement as payment in full, and may charge you for the balance of the bill.

3Enrollees who receive services from Premier dentists will have to pay the difference between the contracted fees at the Premier network level and the amount covered by Delta Dental.

4Based on contracted fees at the PPO network level, you will have to pay the difference between the total fee charged and the amount covered by Delta Dental.

5Delta Dental of Pennsylvania does not require pre-authorization for services. Delta Dental strongly recommends enrollees ask their dentists to seek a pre-treatment estimate (also known as a predetermination of benefits) before receiving services that are expected to exceed $300.

*Network includes 156,528 dentists in 364,136 locations within Delta Dental PPO and Delta Dental Premier-only dentists. 

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