| |
Delta Dental PPO |
Aetna DMO |
| |
In-Network |
Premier Out-of-Network |
Out-of-Network |
In-Network Only |
| Annual Deductible |
$50 individual/$150 family |
None |
| Annual Maximum |
$2,000 |
$1,500 |
$1,500 |
None |
| Covered Expenses |
Preventive Care
- Cleanings
- Routine oral exams
- Fluoride treatments
- X-rays, bitewing
- X-rays, full mouth
|
No charge - up to 3 per year |
100% of Premier Contracted Fee |
100% of R&C |
No charge - up to 2 per year |
| Basic Services |
80% |
70% of Premier Contracted Fee |
70% of R&C |
You pay fixed dollar amount per service |
| Major Services |
50% |
40% of Premier Contracted Fee |
40% of R&C |
You pay fixed dollar amount per service |
| Orthodontia |
50% with $25 deductible
$2,000 lifetime maximum
|
40% of Premier Contracted Fee with $25 deductible
$1,000 lifetime maximum
|
40% of R&C with $25 deductible
$1,000 lifetime maximum
|
You pay $30 exam
Plan covers $1,845 per individual |