Dental
All dental plans are through Delta Dental and are fully insured plans
Non-EHB Dental Benefit Plans #5055
Plan A (2XXX)
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Plan B (3XXX)
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Plan C (4XXX)
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Plan D (1XXX)
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Delta Dental PPO
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Delta Dental PPO
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Delta Dental PPO
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Delta Dental PPO | |||||
PPO Dentist
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Premier or Nonpar
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PPO Dentist
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Premier or Nonpar
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PPO Dentist
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Premier or Nonpar
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PPO Dentist
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Premier or Nonpar
|
|
Diagnostic and Preventive | ||||||||
Diagnostic Services and Preventive Services (Exams, Cleanings, Fluoride, and space maintainers) |
100%
|
100%
|
100%
|
100%
|
50%
|
50%
|
100%
|
75%
|
Brush Biopsy (to detect oral cancer) |
100%
|
100%
|
100%
|
100%
|
50%
|
50%
|
100%
|
75%
|
Radiographs (X-rays) |
100%
|
100%
|
100%
|
100%
|
50%
|
50%
|
100%
|
75%
|
Emergency Palliative Treatment (to temporarily relieve pain) |
100%
|
100%
|
100%
|
100%
|
50%
|
50%
|
100%
|
50%
|
Basic Services | ||||||||
Oral Surgery Services (extractions and dental surgery) |
90%
|
80%
|
80%
|
50%
|
50%
|
50%
|
50%
|
50%
|
Minor Restorative Services (fillings and crown repair) |
90%
|
80%
|
80%
|
50%
|
50%
|
50%
|
50%
|
50%
|
Periodontics (to treat gum disease) |
90%
|
80%
|
80%
|
50%
|
50%
|
50%
|
50%
|
50%
|
Endodontics (root canals) |
90%
|
80%
|
80%
|
50%
|
50%
|
50%
|
50%
|
50%
|
Relines and Repairs (to bridges and dentures) |
90%
|
80%
|
80%
|
50%
|
50%
|
50%
|
50%
|
50%
|
Other Basic Services (misc. services) |
90%
|
80%
|
80%
|
50%
|
50%
|
50%
|
50%
|
50%
|
TMD (treatment of the disorder of the temporomandibular joint) |
60%
|
50%
|
50%
|
50%
|
50%
|
50%
|
50%
|
50%
|
Major Services | ||||||||
Prosthodontics (bridges, dentures and implants) |
60%
|
50%
|
50%
|
50%
|
50%
|
50%
|
50%
|
50%
|
Major Restorative Services (crowns) |
60%
|
50%
|
50%
|
50%
|
50%
|
50%
|
50%
|
50%
|
Orthodontic Services | ||||||||
Orthodontic Services (braces) |
50%
|
50%
|
50%
|
50%
|
50%
|
50%
|
50%
|
50%
|
Orthodontic Age Limit |
19
|
19
|
19
|
19
|
19
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19
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No age limit
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No age limit
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Maximum Benfits per person | ||||||||
Maximum Payment (per person per calendar year on Diagnostic & Preventive, Basic Services and Major Services) |
1,500
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1,200
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1,000
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1,000
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||||
Per person lifetime maximum payment for Orthodontic Services |
1,000
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1,000
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1,000
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1,000
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Coalition of Public Safety Employees Health Trust
Certified-EHB Dental Benefit Plans #5055
Plan A (2XXX)
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Plan B (3XXX)
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Plan C (3XXX)
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Plan D (3XXX)
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Legacy (Non-EHB overage 19)
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EHB (Under Age 19)
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Legacy (Non-EHB overage 19)
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EHB (Under Age 19) |
Legacy (Non-EHB overage 19)
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EHB (Under Age 19)
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Legacy (Non-EHB overage 19)
|
EHB (Under Age 19) | |||||||||
PPO Dentist
|
Premier or Nonpar
|
PPO Dentist
|
Premier or Nonpar
|
PPO Dentist
|
Premier or Nonpar
|
PPO Dentist
|
Premier or Nonpar
|
PPO Dentist
|
Premier or Nonpar
|
PPO Dentist
|
Premier or Nonpar
|
PPO Dentist
|
Premier or Nonpar
|
PPO Dentist
|
Premier or Nonpar
|
|
Diagnostic and Preventive | ||||||||||||||||
Diagnostic Services and Preventive Services (Exams, Cleanings, Fluoride, and space maintainers) |
100%
|
100%
|
100%
|
100%
|
100%
|
100%
|
100%
|
100%
|
50%
|
50%
|
100%
|
80%
|
100%
|
75%
|
100%
|
80%
|
Brush Biopsy (to detect oral cancer) |
100%
|
100%
|
100%
|
100%
|
100%
|
100%
|
100%
|
100%
|
50%
|
50%
|
100%
|
80%
|
100%
|
75%
|
100%
|
80%
|
Radiographs (X-rays) |
100%
|
100%
|
100%
|
100%
|
100%
|
100%
|
100%
|
100%
|
50%
|
50%
|
100%
|
80%
|
100%
|
75%
|
100%
|
80%
|
Emergency Palliative Treatment (to temporarily relieve pain) |
100%
|
100%
|
100%
|
100%
|
100%
|
100%
|
100%
|
100%
|
50%
|
50%
|
100%
|
80%
|
100%
|
50%
|
100%
|
80%
|
Sealants (to prevent decay of permanent teeth) |
0%
|
0%
|
100%
|
100%
|
0%
|
0%
|
100%
|
100%
|
0%
|
0%
|
100%
|
80%
|
0%
|
0%
|
100%
|
80%
|
Basic Services | ||||||||||||||||
Oral Surgery Services (extractions and dental surgery) |
90%
|
80%
|
80%
|
60%
|
80%
|
50%
|
80%
|
60%
|
50%
|
50%
|
50%
|
50%
|
50%
|
50%
|
50%
|
50%
|
Minor Restorative Services (fillings and crown repair) |
90%
|
80%
|
80%
|
60%
|
80%
|
50%
|
80%
|
60%
|
50%
|
50%
|
50%
|
50%
|
50%
|
50%
|
50%
|
50%
|
Periodontics (to treat gum disease) |
90%
|
80%
|
80%
|
60%
|
80%
|
50%
|
80%
|
60%
|
50%
|
50%
|
50%
|
50%
|
50%
|
50%
|
50%
|
50%
|
Endodontics (root canals) |
90%
|
80%
|
80%
|
60%
|
80%
|
50%
|
80%
|
60%
|
50%
|
50%
|
50%
|
50%
|
50%
|
50%
|
50%
|
50%
|
Relines and Repairs (to bridges and dentures) |
90%
|
80%
|
80%
|
60%
|
80%
|
50%
|
80%
|
60%
|
50%
|
50%
|
50%
|
50%
|
50%
|
50%
|
50%
|
50%
|
Other Basic Services (misc. services) |
90%
|
80%
|
80%
|
60%
|
80%
|
50%
|
80%
|
60%
|
50%
|
50%
|
50%
|
50%
|
50%
|
50%
|
50%
|
50%
|
TMD (treatment of the disorder of the temporomandibular joint) |
60%
|
50%
|
0%
|
0%
|
50%
|
50%
|
0%
|
0%
|
50%
|
50%
|
0%
|
0%
|
50%
|
50%
|
0%
|
0%
|
Major Services | ||||||||||||||||
Prosthodontics (bridges, dentures and implants) |
60%
|
50%
|
50%
|
50%
|
50%
|
50%
|
50%
|
50%
|
50%
|
50%
|
50%
|
50%
|
50%
|
50%
|
50%
|
50%
|
Major Restorative Services (crowns) |
60%
|
50%
|
50%
|
50%
|
50%
|
50%
|
50%
|
50%
|
50%
|
50%
|
50%
|
50%
|
50%
|
50%
|
50%
|
50%
|
Implants (endosteal implants to replace missing teeth) |
60%
|
50%
|
0%
|
0%
|
50%
|
50%
|
0%
|
0%
|
50%
|
50%
|
0%
|
0%
|
50%
|
50%
|
0%
|
0%
|
Orthodontic Services | ||||||||||||||||
Orthodontic Services (braces) |
50%
|
50%
|
0%
|
0%
|
50%
|
50%
|
0%
|
0%
|
50%
|
50%
|
0%
|
0%
|
50%
|
50%
|
0%
|
0%
|
Orthodontic Age Limit |
19
|
19
|
N/A
|
N/A
|
19
|
19
|
N/A
|
N/A
|
19
|
19
|
N/A
|
N/A
|
No age limit
|
No age limit
|
N/A
|
N/A
|
Maximum Benfits per person | ||||||||||||||||
Maximum Payment (per person per calendar year on Diagnostic & Preventive, Basic Services and Major Services) |
1,500
|
None
|
1,200
|
None
|
1,000
|
None
|
1,000
|
None
|
||||||||
Per person lifetime maximum payment for Orthodontic Services |
1,000
|
N/A
|
1,000
|
N/A
|
1,000
|
N/A
|
1,000
|
N/A
|
||||||||
Deductible |
None
|
None
|
None
|
None
|
None
|
$25 / $75
|
None
|
$25 / $75
|