Office of Human Resources - Benefits Design & Management
Dental Plans Comparison Chart for 2009-2010 | MAIN OPEN ENROLLMENT PAGE | DENTAL MAIN
SERVICES |
Total Dental Administrators |
Delta Dental |
|
| PLAN TYPE | Prepaid/DHMO | Indemnity/PPO | |
| DEDUCTIBLES | None | $50/$150 | |
| PREVENTATIVE CARE | CoPay | CoInsurance | |
| Office Visit | $0 | $0 - Deductible Waived* | |
| Oral Exam | $0 | $0 - Deductible Waived* | |
| Prophylaxis/Cleaning | $0 | $0 - Deductible Waived* | |
| Fluoride Treatment (to age 19) | $0 | $0 - Deductible Waived* | |
| X-Rays | $0 | $0 - Deductible Waived* | |
| BASIC RESTORATION | |||
| Office Visit | $0 | $0 | |
| Sealants | $10 per tooth | 20% | |
| Fillings | Amalgam: $10-$37; Resin: $26-$76 | 20% | |
| Extractions | Simple: $30; Surgical: $60 | 20% | |
| Periodontal Gingivectomy | $225 | 20% | |
| Oral Surgery | $30-$145 | 20% | |
| MAJOR RESTORATIVE | |||
| Office Visit | $0 | $0 | |
| Crowns | $270 + $185 Lab Fee ($455) | 50% | |
| Dentures | $300 + $275 Lab Fee ($575) | 50% | |
| Fixed Bridgework | $270 + $285 Lab Fee ($455) per unit | 50% | |
| Crown/Bridge Repair | $75 | 50% | |
| Inlays | $250-$327 | 50% | |
| ORTHODONTIA | |||
| Child | $2800-$3400 | $1500 per person in a lifetime | |
| Adult | $3200-$3700 | $1500 per person in a lifetime | |
| TMJ SERVICES | |||
| Exam, services, etc | 20% Discount | ||
| MAXIMUM BENEFITS | |||
| Annual Combined Preventive, Basic and Major services | No Dollar Limit | $2000 per person | |
| Orthodontia Lifetime | No Dollar Limit | $1500 per person | |
| INTERNATIONAL COVERAGE | |||
| Emergency Only | Coverage is available under non-participating provider beneftis |
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| * Routine visits and exams are covered only two times per year at 100%. | |||
IMPORTANT: All PPO benefits are subject to reasonable and customary charges as defined by the insurance industry This is a summary only; See plan descriptions for detailed provisions. |
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