Small Group PPO Plus Premier Benefit Summaries 4 & 6
(10-50)
PPO Plus Premier 4
100/80/50 plan
with 3 maximum options
Calendar year maximum
PPO/Premier OON
per enrollee
$2,000/
$1,500,
$3,000/
$2,500 or
$5,000/
$4,500
Ortho maximum
$1,000
Deductible
PPO/Premier & OON
per person/per family (excluding P&D)
$50/
$150
PPO Plus Premier 4
Enhanced Ortho 1500
100/80/50 plan
with 3 maximum options
Calendar year maximum
PPO/Premier & OON
per enrollee
$2,000/
$1,500,
$3,000/
$2,500 or
$5,000/
$4,500
Ortho maximum
$1,500
Deductible
PPO/Premier & OON
per person/per family (excluding P&D)
$50/
$150
PPO Plus Premier 4
Max Ortho
2000
100/80/50 plan
with 3 maximum options
Calendar year maximum
PPO/Premier & OON
per enrollee
$2,000/
$1,500,
$3,000/
$2,500 or
$5,000/
$4,500
Ortho maximum
$2,000
Deductible
PPO/Premier & OON
per person/per family (excluding P&D)
$50/
$150
PPO Plus Premier 6
100/100/60 plan
with 3 maximum options
Calendar year maximum
PPO/Premier & OON
per enrollee
$1,500/
$1,000,
$2,000/
$1,500 or
$5,000/
$4,500
Ortho maximum
$1,000
Deductible
PPO/Premier & OON
per person/per family (excluding P&D)
$50/
$150 or
$75/
$225
PPO Plus Premier 6
Enhanced Ortho 1500
100/100/60
with 3 maximum options
Calendar year maximum
PPO/Premier & OON
per enrollee
$1,500/
$1,000,
$2,000/
$1,500 or
$5,000/
$4,500
Ortho maximum
$1,500
Deductible
PPO/Premier & OON
per person/per family (excluding P&D)
$50/
$150 or
$75/
$225
PPO Plus Premier 6
Max Ortho
2000
100/100/60
with 3 maximum options
Calendar year maximum
PPO/Premier & OON
per enrollee
$1,500/
$1,000,
$2,000/
$1,500 or
$5,000/
$4,500
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.
The Special Health Care Needs Benefit from Delta Dental: Helping to break down barriers to care by providing eligible covered members with an enhanced benefit
Combining Deltavision with your Delta Dental benefits provides you with the convenience and affordability of two excellent programs in a single package
"Virtual Visits" service is provided by Teledentistry.com. This service is a covered benefit in most Delta Dental of New Jersey plans for currently enrolled members.
We've partnered with Amplifon Hearing Health Care to offer members access to a NO-COST hearing savings program that brings members huge savings on hearing aids and services.
