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Plan Description
Carrier Name >Delta Preferred Option
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Note: This page contains a brief summary of coverage. It does not
state all provisions and limitations of the plan. The terms and provisions of
each plan, as outlined in the plan document, will determine coverage and
eligibility.
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PCP In Network
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Preferred In
Network
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Out of
Network
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General Plan Information
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Annual Deductible/Individual
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$0
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$0
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Not Covered
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Annual Deductible/Family
| $0
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$0
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Not Covered
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Deductible Waived for Preventive
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Yes
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Yes
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Yes
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Annual Plan Maximum
| $2,000
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$1,500
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$500
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Lifetime Orthodontia Plan Maximum
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$1,000
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$500
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No Covered
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Reasonable & Customary Percentile
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90%
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80%
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Not Covered
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Waiting Period
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30 days
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60 days
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180 days
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Diagnostic and Preventive Services
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Diagnostic and Preventive
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80%
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50%
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Not Covered
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Oral Exams
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80%
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50%
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Not Covered
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X-Rays
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80%
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50%
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Not Covered
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Prophylaxis Treatments
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80%
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50%
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Not Covered
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Fluoride Treatments
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80%
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50%
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Not Covered
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Space Maintainers
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80%
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50%
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Not Covered
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Sealants
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80%
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50%
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Not Covered
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Waiting Period Information
Eligible employees are eligible as of the 1st of the month following the employee's hire date.
Termination of Coverage Information
When a plan participant is terminated from the company, the plan coverage ends on the last day of the month following the employee's termination date.
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(per month)
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Employee
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$90.80
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Employee + Spouse
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$24.32
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Employee + Child(ren)
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$45.32
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Family
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$154.15
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Delta Dental Plan of Michigan
Member Services
John Carpet
P.O. Box 173
Detroit, MI
80217
(303) 741-9300
Fax (303) 225-3453
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