What is covered
Select Plan
coverage
Select Plus Plan coverage
(no out-of-network coverage)
Delta Dental PPO only
Delta Dental PPO and Delta Dental Premier
Annual deductible
$100 / person
$25 / person
Annual Maximum
$1,000 / person
$2,500 / person
Routine evaluations, dental cleaning, sealants, bitewing and panoramic x-rays, fluoride treatments, pulp vitality tests
No coverage
No coverage
In-network providers
Fillings
No coverage
No coverage
Periodontal maintenance
No coverage
No coverage
Surgical extraction,
root canal
periodontics
oral surgery
50%
80%
(endodontics),
(except maintenance,
Crowns, bridges, dentures, implants
50%
60%
(above gumline)
Non-surgical extractions
No coverage
No coverage
Orthodontics coverage
No coverage
50% (regardless of age)
Orthodontics lifetime maximum
No coverage
$1,500*
*In addition to the $1,500 from the UDB or Preventive Plan, $3,000 total for dependent children.