Dental Insurance
Administered by Delta Dental
Good oral care enhances overall physical health , appearance and mental well-being . Problems with the teeth and gums are common and easily treated health problems . Keep your teeth healthy and your smile bright with the Davis Behavioral Health dental benefit plan .
PPO Plan PPO / Premier
Network Dentist Non-Network Dentist ** Plan Year July 1 - June 30 July 1 - June 30
Deductible
Applies to Basic and Major services .
Preventive
Routine exams , cleanings ( 2 per year ), topical fluoride , x-rays
Basic
Fillings , extractions , oral surgery , endodontics , and periodontics
Major
Crowns , bridges , dentures , and full implants
Orthodontics
Children and Adults
$ 25 per person $ 75 family max
$ 25 per person $ 75 family max
100 % 100 % of R & C
80 % 80 % of R & C
50 % 50 % of R & C 6-month waiting period *
50 % 50 % of R & C
6-month waiting period * All Members 20 % discount No discount
Maximum Benefit
Preventive , Basic and Major services per person per year .
$ 1,500
Specialists
Endodontists , Oral Surgeons , Periodontists , Prosthodontists , Pediatric Specialists
Member is responsible for the difference between the Plan ’ s payment and the discounted Specialist ’ s fee .
Member is responsible for the difference between the Plan ’ s payment and the discounted Specialist ’ s fee .
* Waiting period is applicable to new enrollees only . The waiting period can be reduced if you provide documentation ( within 45 days of your dental coverage effective date ) that you were enrolled in comparable dental coverage with no break immediately prior to your effective date on the DBH dental plan .
** Reasonable and Customary ( R & C ): means benefits based only on “ Reasonable and Customary ” fee criteria . Delta Dental will allow up to the reasonable and customary charge for the dental procedures and services after the required deductible amount , as shown . Charges above the plan payment are the patient ’ s responsibility .
The benefits illustrated are in summary form only . They should not be construed as complete in and of themselves . They are only for comparison and in the case of a discrepancy , the plan documents apply .
Please refer to the Group Certificate Booklet for a complete description of benefits , limitations , and exclusions .
Davis Behavioral Health
16