Small Group PPO Ortho Benefit Summaries - 4 & 6

(10-50)

Small Group Plan Headers_PPO

 
 

PPO 4


100/80/50 plan
with 3 maximum options








Calendar year maximum
PPO/Premier OON
per enrollee

$1,500, $2,000, or $5,000

Ortho maximum

$1,000

Deductible
PPO/Premier & OON
per person/per family
(excluding P&D)

$50/
$150

PPO 4
Enhanced Ortho 1500

100/80/50 plan
with 3 maximum options








Calendar year maximum
PPO/Premier & OON
per enrollee

$1,500/
$2,000 or
$5,000

Ortho maximum

$1,500

Deductible
PPO/Premier & OON
per person/per family
(excluding P&D)

$50/
$150

PPO 4
Max Ortho
2000

100/80/50 plan
with 3 maximum options








Calendar year maximum
PPO/Premier OON
per enrollee

$1,500, $2,000, or $5,000

Ortho maximum

$2,000


Deductible
PPO/Premier & OON
per person/per family
(excluding P&D)


$50/
$150

PPO 6


100/100/60 plan
with 3 maximum options








Calendar year maximum
PPO/Premier & OON
per enrollee

$1,500, $2,000 or $5,000

Ortho maximum

$1,000


Deductible
PPO/Premier & OON
per person/per family
(excluding P&D)


$50/
$150 or
$75/
$225

PPO 6
Enhanced Ortho 1500

100/100/60
with 3 maximum options








Calendar year maximum
PPO/Premier & OON
per enrollee

$1,500,
$2,000 or
$5,000

Ortho maximum

$1,500

Deductible
PPO/Premier & OON
per person/per family
(excluding P&D)

$50/
$150 or
$75/
$225

PPO 6
Max Ortho
2000

100/100/60
with 3 maximum options








Calendar year maximum
PPO/Premier & OON
per enrollee

$1,500, $2,000 or $5,000

Ortho maximum

$2,000

Deductible
PPO/Premier & OON
per person/per family
(excluding P&D)

$50/
$150 or
$75/
$225






 

This is a summary of deductible, coinsurance, out-of-pocket limits, and other components of plan design. All coverage provisions, limitations and exclusions can be found in the group contract and certificate of coverage. Some Covered Services for Pediatric Enrollees require that you obtain a Prior Authorization from us before the service is performed. The covered dental services that require Prior Authorization are described in the certificate of coverage. Where Prior Authorization is required but not obtained, Delta Dental can apply a penalty of up to 50% of the charges that would otherwise be covered.

Transparency in coverage


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