Plan 1500 Use Any Dentist

DPO Option  II

Plan  III Use Any Dentist

Calendar Year Deductible $50.00*
*Deductible waived for items covered at 100%

In Network

Out of Network

In Network

Out of Network

In Network

Out of Network

Preventive and Diagnostic
(frequencies shown below)
Emergency treatment for relief of pain
Routine Exams, Cleaning
Bitewing X-rays, Full Mouth X-rays
Fluoride Treatment
Space Maintainers

100%

100%

100%

50%

80%

80%

Basic Dental Services
Restorative - Amalgam or Synthetic Fillings
Sealants (frequencies shown below)
Oral Surgery
Extractions, Impacted Teeth, Cysts and Neoplasms, Alveolar/Gingival Reconstructions
Periodontics-Includes treatment for diseases of the gums
Endodontics-Root canals and Pulpal Therapy

80%

80%

80%

50%

80%

80%

Major Dental Services
     Subject to a 12 month waiting period.
    Can this waiting period be waived? Effective March 1, 2002, All new groups with 20 or more employees enrolling in any Wolfpack Insurance Services Delta Dental plan will automatically have the waiting period for Major and Orthodontic services waived.
For groups of 5 employees or more, the 12 month waiting period for Major Dental Services will be waived on all employees who had continuous dental coverage during the preceding 12 months. The 12 month Orthodontic waiting period will also be waived if the group had continuous orthodontic coverage during the preceding 12 months.
Restorative - Inlays and Crowns
Prosthodontics- Dentures and Partials

50%

50%

50%

Calendar Year Maximum, Benefit per Individual

$1500

$1500

$1500

Optional Orthodontic Benefit
Maximum lifetime benefit $1500.  Subject to a 12 month waiting period.  Utilize any provider.
Can this waiting period be waived?

50%

50%

50%