C.O.P.S Trust

All dental plans are through Delta Dental and are fully insured plans

Non-EHB Dental Benefit Plans #5055

	Plan A (2XXX)		Plan B (3XXX)		Plan C (4XXX)		Plan D (1XXX)
	Delta Dental PPO		Delta Dental PPO		Delta Dental PPO		Delta Dental PPO
	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%	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	19	No age limit	No age limit
Maximum Benfits per person
Maximum Payment (per person per calendar year on Diagnostic & Preventive, Basic Services and Major Services)	1,500		1,200		1,000		1,000
Per person lifetime maximum payment for Orthodontic Services	1,000		1,000		1,000		1,000

 

Coalition of Public Safety Employees Health Trust

Certified-EHB Dental Benefit Plans #5055

	Plan A (2XXX)				Plan B (3XXX)				Plan C (3XXX)				Plan D (3XXX)
	Legacy (Non-EHB overage 19)		EHB (Under Age 19)		Legacy (Non-EHB overage 19)		EHB (Under Age 19)		Legacy (Non-EHB overage 19)		EHB (Under Age 19)		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