Dental
Taking care of your oral health is not a luxury; it is a necessity for long-term optimal health. With a focus on prevention, early diagnosis, and treatment, Dental insurance can greatly reduce your costs when it comes to restorative and emergency procedures.
When you visit a dentist in the network, you will maximize your savings. These dentists have agreed to reduced fees, which means you won’t get charged more than your expected share of the bill.
Dental Plan 1
Plan Information
Plan Name: Delta Dental HMO
Policy Number: 22222
Effective Date: 01/01/2025
Provider Network: Delta Dental
In-Network Benefit Highlights
Deductible (Individual/Family)
$XX/$XX
Out-of-Pocket Max (Individual/Family)
$XX/$XX
Preventive Care
$XX
Primary Care Visit
$XX
Specialist Visit
$XX
Urgent Care
$XX
Emergency Room
$XX
Benefit Highlights
In-Network Only
Deductible (Per Individual)
None
Out-of-Pocket Max (Individual/Family)
Unlimited
Diagnostic and Preventive
$0–$45 copay, then 0% (varies by service; see contract for fee schedule)
Basic Services
$0–$195 copay, then 0% (varies by service; see contract for fee schedule)
Major Procedures
$0–$195 copay, then 0% (varies by service; see contract for fee schedule)
Orthodontia (Adults and Children)
$1,700–$1,900 copay, then 0% (see contract for fee limitations) (Unlimited lifetime max)
Children: Covered
Adults: Covered
Plan Documents
Dental Plan 1 Summary
Contact Information
Dental Plan 2
In-Network Benefit Highlights
Benefit Highlights
In-Network
Deductible (Individual/Family)
$50/$150
Out-of-Pocket Max
$1,500 per individual
Diagnostic and Preventive
100% covered
Basic Services
20%*
Major Procedures
50%*
Orthodontia (Adults and Children)
50% ($1,500 lifetime max)
Children: Covered to age 19
Adults: Not covered
* After deductible
** Combined with in-network
Out-of-Network
Deductible (Individual/Family)
$50/$150**
Out-of-Pocket Max
$1,500 per individual**
Diagnostic and Preventive
100% covered
Basic Services
20%*
Major Procedures
50%*
Orthodontia (Adults and Children)
50%; $1,500 lifetime max**
Children: Covered to age 19
Adults: Not covered
Plan Documents
Contact Information
Dental Plan 3
In-Network Benefit Highlights
Benefit Highlights
Level 1
Deductible (Individual/Family)
None
Out-of-Pocket Max
$2,000 per individual
Diagnostic and Preventive
100% covered
Basic Services
100% covered
Major Procedures
30%
Orthodontia (Adults and Children)
50%; $1,500 lifetime max
Children: Covered
Adults: Covered
–
Level 2
Deductible (Individual/Family)
$25/$75
Out-of-Pocket Max
$2,000 per individual**
Diagnostic and Preventive
100% covered
Basic Services
20%*
Major Procedures
50%*
Orthodontia (Adults and Children)
50%; $1,500 lifetime max**
Children: Covered
Adults: Covered
Level 3
Deductible (Individual/Family)
$50/$150***
Out-of-Pocket Max
$2,000 per individual**
Diagnostic and Preventive
20%
Basic Services
40%*
Major Procedures
60%*
Orthodontia (Adults and Children)
50%; $1,500 lifetime max**
Children: Covered
Adults: Covered
* After deductible
** Combined with level 1
*** Combined with Level 2
Plan Documents
Dental Plan 3 Summary