|
ODS Health Plans of
Oregon
Index | Dental
Rates | Premier Benefits | Preferred PPO Benefits | Download Application
Delta Dental Preferred PPO Dental
Plan Benefits
| Plan year maximum, per
member |
|
|
First year benefit maximum
|
$750 |
|
Second year benefit maximum
|
$1,000 |
|
Third year benefit maximum
|
$1,250 |
| Plan year deductible, per
member |
$50 |
| Service |
Benefit |
| Preventive |
Examinations/x-rays (routine exam
& bitewing x-rays)
Prophylaxis (cleanings)
Fissure sealants
Fluoride
|
|
PPO
Network |
Non-PPO
Network |
| 100%** |
80% |
| Basic - Six Month Waiting Period |
Restorative dentistry (treatment
of tooth decay with amalgam, synthetic porcelain
and plastic materials)
Space maintainers
|
|
60% |
50% |
| Major - Twelve Month Waiting Period |
Oral Surgery (surgical extractions
& certain minor surgical procedures)
Endodontic (pulp therapy and root
canal filling)
Periodontics (treatment of tissues
supporting the teeth)
Crowns
Cast restorations
Dentures and bridge work (construction
or repair of fixed bridges, partials and
complete dentures)
|
|
50% |
50% |
** Deductible waived only in PPO network
When the member visits:
- Preferred Dentists: Benefits are paid at the In Network benefit level. Members are held harmless from balance billing by professionals
- Non Preferred ODS Participating Dentists: Benefits are paid at the Out of Network benefit level. Members are held harmless from balance billing by professionals
- Non Preferred, Non Participaing Dentists: Benefits are paid at the Out of Network level
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