What types of services are covered?

The Delta Dental PPO – Point of Service program features the perfect combination of access and savings. Individuals/Families choosing this option will access 4 classes of benefits, a $1,000 annual maximum per member per year for Classes 1, 2, & 3. A separate $1,000 lifetime maximum applies to Class 4 services (orthodontics) per eligible dependent child under age 19. A $50 deductible applies to Class 2 services per person per year and a $200 deductible applies to Class 3 services per person per year.

Although you may see any licensed dentist, your out-of-pocket expenses will be lower when you utilize a Delta Dental PPO or Delta Dental Premier participating dentist.

This table summarizes your coverage:

Benefit Examples	Delta Dental PPO	Delta Dental Premier	Out of Network
Class I: Diagnostic & Preventive Exams, cleanings, X-rays, etc.	100%	80%	70%
Class II: Basic Restorative Fillings, simple extractions, oral surgery, root canal therapy, etc. After a $50 deductible per person per year and an initial 6-month waiting period	80%	60%	50%
Class III: Major Restorative Crowns, dentures, implants, etc. After a $200 deductible per person per year and an initial 12-month waiting period	50%	30%	20%
Class IV: Orthodontic Services The necessary treatment and procedures required for the correction of malposed teeth. Available to eligible Dependent Children under age 19 (initial waiting period of 18 months)	50%	50%	30%
Annual Maximum - $1,000 per person per dependent child Lifetime Ortho Maximum - $1,000
Note: Percentages listed are the portion of the dentist’s fee that Delta Dental of Oklahoma will pay toward covered services subject to the maximum allowable charge or prevailing fee as determined by DDOK. Plan limitations and exclusions apply.

Examples of Covered Services & Co-payments With Delta Dental PPO – Point of Service, you may see any licensed dentist; however, your out-of-pocket expenses will be lower typically when treatment is performed by a Delta Dental participating dentist. For example, payment of a covered Class II dental service is illustrated below (the illustration assumes the annual deductible has been satisfied).

Delta Dental PPO Dentist		Delta Dental Premier Dentist		Non-Participating Dentist (out-of-network)
PPO Dentist Charge	$100	Premier Dentist Charge	$100	Dentist Charge	$100
PPO Maximum Allowable	$70	Premier Maximum Allowable	$85	Prevailing Fee	$75
Plan Pays (80% of Delta Dental PPO Maximum Allowable)	$56	Plan Pays (60% of Delta Dental Premier Maximum Allowable)	$51	Plan Pays (50% of the Prevailing Fee)	$37.50
You Pay*	$14	You Pay*	$34	You Pay*	$62.50
*20% of Delta Dental PPO Allowable		*40% of the Delta Dental Premier Allowable		*Balance of the dentist charge

Are there waiting periods?

Yes. To help keep your premiums low, there are waiting periods for Class 2, Class 3 and Class 4 services. However, you are eligible for Class 1 services immediately.

Note: If you provide proof of previous comparable coverage and apply within 60 days of the date your previous coverage terminated, we will review your previous coverage and, in most cases, provide credit toward certain waiting periods.

• No waiting for Class 1 Services - (Cleanings, exams, x-rays, etc)
• 6 months for Class 2 Services - (Fillings, oral surgery, etc)
• 12 months for Class 3 Services - (Crowns, bridges, dentures, etc)
• 18 months for Class 4 Services - (Orthodontics - available to eligible dependent children under age 19)