1. Dental Plan Comparison – Delta Dental
High Plan
Standard Plan
Plan Type
PPO
In Network
Out of Network
Plan Design:
Individual Deductible
$25
$50
$100
Family Deductible
$150
Annual Max (Non-Ortho)
$1,750
$1,250
$1,500
$1,000
Preventive Care
100%
100% U&C Applies
Class II - Basic Restorative
80% subject to deductible
80% subject to deductible, subject to U&C
60% subject to deductible
60% subject to deductible, subject to U&C
Class III - Major Restorative
50% subject to deductible
50% subject to deductible, subject to U&C
Class IV - Ortho (including child and adults)
50%
50% subject to U&C
Not Covered
Ortho Life Time Max
Not Applicable
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