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Plan Details

DD PPO Plan II Under 55 has no waiting period for oral exams, bitewing X-rays, teeth cleaning and fluoride treatments. The plan covers 50% of two annual teeth cleanings in or out of network based on Delta Dental’s PPO fee table. This plan has a $50 annual deductible and an annual maximum benefit of $1,000.

  Delta Dental PPO,
 Delta Dental Premier
or Non-participating Dentist
Waiting Periods
Preventive and Diagnostic
Diagnostic and Preventive services* -
Used to evaluate existing conditions and/or to prevent dental abnormalities or diseases (includes exams and cleanings twice per year, bitewing X-rays, and fluoride treatments to age 14)
50% None
Emergency palliative treatment* -
Used to temporarily relieve pain
50% None
Radiographs/diagnostic imaging* -
X-rays as required for routine care or as necessary for the diagnosis of a specific condition
50% 6 Months
Periodontal prophylaxis -
Periodontal maintence following active periodontal therapy
50% 6 Months
Denture Repair -
Relines and repairs to bridges, removable bridges, partial dentures, and complete dentures
50% 6 Months
Minor restorative services—
Used to repair teeth damaged by disease or injury (for example, silver fillings and white fillings)
50% 6 Months
Oral surgery services—
Extractions and dental surgery, including local anesthesia, suturing, if needed, and routine post-operative care
50% 12 Months
Endodontic services—
Used to treat teeth with diseased or damaged nerves (for example, root canals)
50% 12 Months
Periodontic services—
Used to treat diseases of the gums and supporting structures of the teeth
50% 12 Months
Prosthodontic services—
Used to replace missing natural teeth (for example, bridges and dentures)
50% 12 Months
Crown and cast restorations—
Tooth restorations including metal and porcelain crowns
50% 12 Months
TMD treatment—
Treatment for jaw and facial joint disorders
50% 12 Months
Maximums and deductible
Contract year maximum $1,000 per member
Lifetime maximums $300 - TMD
Deductible (per contract year) *Deductible waived for these services $50 per member

**Plan II—Payment is always based on dentist’s submitted fee or the Delta Dental PPO dentist fee schedule, whichever is less.

NOTES: The above summary is a sample of benefits. Policies have exclusions and limitations that may limit coverage. For complete coverage details, please refer to your policy. These dental plans are available exclusively to members of organizations offering Delta Dental to them. The policy term is one year. Coverage may be terminated for reasons stated in the policy. Coverage ceases upon termination of the policy. Products and services referred to on this web site are not available in all states or jurisdictions. Underwritten by Renaissance Life & Health Insurance Company of America, Indianapolis, IN, and in New York by Renaissance Health Insurance Company of New York, New York, NY. Both companies may be contacted at: PO Box 1596, Indianapolis, IN 46206.

Waiting Periods on Types of Services
Preventive None
Diagnostic X-rays 6 months
Basic 6 months
Major 12 months

Preventive care
  • Routine oral exams – two per benefit year
  • Prophylaxis (cleaning and scaling of teeth) – two per benefit year
Diagnostic care
  • Bitewing X-rays - one per benefit year
Basic care
  • Full-mouth X-rays (panoramic film)
  • Fillings (restorations) – amalgam restorations, composite restorations for anterior teeth and bicuspids, and sedative fillings
  • Maintenance prosthodontics
Major care
  • Simple extraction
  • Periodontic services
  • Inlays, onlays and crowns
  • Prosthetic services – dentures or bridges
  • Endodontics (root canals)
  • Oral surgery