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Delta Dental PPO Summary
Like the Premier plan, this preferred providerA provider contracted within a network. By choosing a preferred provider, the member's out-of-pocket expenses will be less than if he or she chooses a physician outside the network. option offers access to the largest PPO network in Oregon and across the country. The Delta Dental PPO plan, however, offers a unique feature: it is the only PPO program in the nation with a built-in "safety net" that protects members from balance billing when they seek services outside of the PPO network.
*Waiting period may be waived by creditable prior coverage from a comparable plan. This is a benefit summary only. For a complete description of benefits, refer to your Policy. Effective November 1, 2008 through October 31, 2009 |
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| Plan yearThe 12-month period commencing on the effective date and each 12-month period thereafter. maximum, per member | $750: 1st year $1,000: 2nd year $1,250: 3rd year |
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| Plan year deductible, per member | $50 | |
| Service | Benefit | |
|---|---|---|
| PPO Network | Non-PPO Network | |
| Class 1: Examinations/X-rays (routine exam and bitewing X-rays once every six months); prophylaxis (cleanings once every six months); fissure sealants; fluoride | 100% | 80% |
| Class 2: Restorative dentistry (treatment of tooth decay with amalgam, synthetic porcelain and plastic materials); space maintainers | 80% | 50% |
| Class 3: Oral surgery (surgical extractions and certain minor surgical procedures); endodontics and periodontics; 12-month waiting period on major services*: crowns; cast restorations; dentures and bridge work (construction or repair of fixed bridges, partials and complete dentures) | 50% | 50% |