Tables
Option 10A
Based on tbl1
Table Title
content
content
content
content
content
content
content
content
content
content
Content
content
content
content
content
Your description here…
Option 10B
Based on tbl2
Option 10C
Based on tbl4
In-Network
Out-of-Network*
Annual Benefit
Maximum1
Maximum1
$2,500
$2,500
You Pay
You Pay
Annual Deductible1,2
$50
$50
Preventive Services
No Charge
No Charge
Basic Services
20%
40%
Major Services
(includes implants)
(includes implants)
50%
50%
Orthodontia Adults and Children
50%
Limited to $2,500 per lifetime
Limited to $2,500 per lifetime
50%
Limited to $2,500 per lifetime
Limited to $2,500 per lifetime
Option 10D
Based on xxx
Annual deductible
Annual maximum 1
Diagnostic & Preventive Services 2
Basic Services 3
Major Services 4
Orthodontia
Delta Dental Base DPPO
PPO Network
PPO Network
$75
(per person)
$225
(per family)
(per person)
$225
(per family)
$1,000
(per person)
Diagnostic & Preventive Services do not apply
(per person)
Diagnostic & Preventive Services do not apply
Plan pays 100%
(no deductible)
(no deductible)
Plan pays 85% coinsurnace
(after deductible up to the annual maximum)
(after deductible up to the annual maximum)
Plan pays 50% coinsurance
(after deductible up to the annual maximum)
(after deductible up to the annual maximum)
Not covered
Delta Dental Buy-Up DPPO
PPO and Premier Network
PPO and Premier Network
$50
(per person)
$150
(per family)
(per person)
$150
(per family)
$2,000
(per person)
Diagnostic & Preventive Services do not apply
(per person)
Diagnostic & Preventive Services do not apply
Plan pays 100%
(no deductible)
(no deductible)
Plan pays 100%
(no deductible up to the annual maximum)
(no deductible up to the annual maximum)
Plan pays 50% coinsurance
(after deductible up to the annual maximum)
(after deductible up to the annual maximum)
Plan pays 50% coinsurance
(no deductible up to $1,500 per person per lifetime maximum)
(no deductible up to $1,500 per person per lifetime maximum)