Small Group PPO Plus Premier Benefit Summaries B & D

(10-50)

Small Group Plan Headers_PPO

 
 

PPO Plus Premier B


100/80/50 & 80/60/50 plans
with 3 maximum options







Calendar year maximum
PPO/Premier OON
per enrollee

$1,500/
$1,000,
$2,000/
$1,500 or
$3,000/
$2,500




Ortho maximum

$1,000

Deductible

PPO
per person/per family (excluding P&D)

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




$50/$150







$75/$225

PPO Plus Premier B
Enhanced Ortho 1500

100/80/50 & 80/60/50 plans
with 3 maximum options







Calendar year maximum
PPO/Premier & OON
per enrollee

$1,500/
$1,000,
$2,000/
$1,500 or
$3,000/
$2,500




Ortho maximum

$1,500

Deductible

PPO
per person/per family (excluding P&D)

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




$50/$150







$75/$225

PPO Plus Premier B
Max Ortho
2000

100/80/50 & 80/60/50 plans
with 3 maximum options







Calendar year maximum
PPO/Premier & OON
per enrollee

$1,500/
$1,000,
$2,000/
$1,500 or
$3,000/
$2,500



Ortho
maximum

$2,000

Deductible

PPO
per
person/per
family
(excluding
P&D)

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




$50/$150







$75/$225

PPO Plus Premier D


100/100/60 & 100/80/50 plans
with 3 maximum options







Calendar year maximum
PPO/Premier & OON
per enrollee

$1,500/
$1,000,
$2,000/
$1,500,
$2,000/
$1,500,
$3,000/
$2,500 or
$5,000/
$4,500

Ortho maximum

$1,000

Deductible

PPO
per
person/per
family
(excluding P&D)

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




$50/$150







$75/$225

PPO Plus Premier D
Enhanced Ortho 1500

100/100/60 & 100/80/50 plans
with 3 maximum options







Calendar year maximum
PPO/Premier & OON
per enrollee

$1,500/
$1,000,
$2,000/
$1,500,
$2,500/
$2,000,
$3,000/
$2,500 or
$5,000/
$4,500

Ortho maximum

$1,500

Deductible

PPO
per person/per family (excluding P&D)

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




$50/$150







$75/$225

PPO Plus Premier D
Max Ortho
2000

100/100/60 & 100/80/50 plans
with 3 maximum options







Calendar year maximum
PPO/Premier & OON
per enrollee

$1,500/
$1,000,
$2,000/
$1,500,
$2,500/
$2,000
$3,000/
$2,500 or
$5,000/
$4,500

Ortho maximum

$2,000

Deductible

PPO
per person/per family (excluding P&D)

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




$50/$150







$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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Teledentistry Virtual Visits
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Delta Dental hearing savings program
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