Preferred Prime
Summary of Coverage
|
Delta Dental
PPOTM Dentist
|
Delta Dental
Premier® Dentist
|
|
Deductible
per person per calendar year
|
$50* |
$150* |
$225 |
Annual Benefit Maximum
per person per calendar year
|
$1,000 |
Benefit Categories
|
Coinsurance paid by member |
Diagnostic & Preventive Services
(check-ups, teeth cleaning, x-rays,
maintenance therapy)
|
0% |
0% |
50% |
Routine & Restorative Services
(cavity repair, tooth extractions, general
anesthesia/sedation, restoration of
decayed or fractured teeth, routine oral
surgery)
|
50% |
50% |
70% |
Posterior Composites
(tooth-colored filling on back teeth)
|
60% |
60% |
70% |
Endodontic Services
(root canals and therapy, apicoectomy,
direct pulp cap, retrograde fillings)
6-month waiting period
|
50% |
50% |
70% |
Periodontal Services
(gum and bone diseases, complex
procedures) 6-month waiting period
|
50% |
50% |
70% |
High Cost Restorations
(cast restorations: crowns, inlays, onlays,
posts, cores) 12-month waiting period
|
50% |
50% |
70% |
Prosthetics
(bridges, dentures) 12-month waiting period
|
50% |
50% |
70% |
Implants
12-month waiting period
|
60% |
60% |
70% |
* Deductible is waived for all diagnostic and preventive care.
Additional Resources:
The information on this page summarizes your benefits and payment obligations. This is a general description of your benefits. Please see your benefits document for a full description of coverage.
Prime policies do not include the pediatric dental services as required under the Affordable Care Act (ACA). This coverage is available in the Plus policies. You can purchase policies with the required pediatric dental services on the insurance Marketplace and these plans can be purchased without purchasing a medical plan. Please contact Delta Dental, your insurance agent, or Iowa’s Health Insurance Marketplace if you wish to purchase pediatric dental coverage or a stand-alone dental policy