Plan
Plan Name:
Delta Dental PPO Basic Plan for Families NS OON Dep 25 Family Dental WP
Issuer Name:
Delta Dental of New York, Inc
HIOS ID:
10345NY0010006
Annual Benefit Maximum:
$1,000
Out of Network Coverage:
Y
Dental Plan Type
Dental Plan Type:
Adult & Family Dental Plan
Plan Information
Dep Age:
Age 25
Plan Type:
PPO
Standard or Non-Standard Plan:
Non-Standard
Waiting Periods:
12 months for adult TMJ coverage
Deductible Adult Individual:
$50
Limit Description:
Pediatric: Two (2) dental exams & cleanings per 12 months; Full mouth X-rays or panoramic X-rays at 36 month intervals; bitewing X-rays at six month intervals; Additional details for Pediatric and Adult listed in Contract
Limits on Services:
Yes
Lifetime Benefit Maximum:
$300 lifetime maximum for adult TMJ services
Coverage Level:
Family
Benefits Excluded from In Network MOOP:
Listed in Contract
FDP In Network Cost Sharing Adult Benefits
FDP Office Visit With No Additional Services - Adult:
Not covered
FDP Oral Evaluation - Adult:
CI: 0% AD
FDP Complete Set of X-Rays - Adult:
CI: 0% AD
FDP Topical Fluoride - Adult:
Not covered
FDP Polishing - Adult:
CI: 0% AD
FDP Sealant (per tooth) - Adult:
Not covered
FDP Spacers - Adult:
Not covered
FDP Simple Extraction - Adult:
Not covered
FDP Fillings - Adult:
Not covered
FDP Single Restoration Crowns - Adult:
Not covered
FDP Pulp Cap - Adult:
Not covered
FDP Bonding - Adult:
Not covered
FDP Root Canal - Adult:
Not covered
FDP In Network Cost Sharing Adult Benefits
FDP MOOP Adult Individual:
None
FDP Deductible 2+ Adult Members:
$150
FDP MOOP 2+ Members:
None
FDP Additional In Network Cost Sharing Adult Benefits
FDPA Scaling - Adult:
Not covered
FDPA Gingivectomy or Gingivoplasty - Adult:
Not covered
FDPA Gum Surgery - Adult:
Not covered
FDPA Routine Braces - Adult:
Not covered
FDPA Partial Dentures - Adult:
Not covered
FDPA Complete Dentures - Adult:
Not covered
FDPA Dental Implants - Adults:
Not covered
FDPA Bridges - Adults:
Not covered
FDPA Veneers - Adult:
Not covered
FDPA TMJ - Adult:
CI: 50% AD
FDP In Network Cost Sharing Pediatric Benefits
FDP Deductible Pediatric Individual:
$65
FDP MOOP Pediatric Individual:
$400
FDP Deductible Pediatric 2+ Children:
$195
FDP MOOP Pediatric 2+ Children:
$800
FDP Dental Check-Up - Child:
CI: 0% AD
FDP Basic Dental Care - Child:
CI: 50% AD
FDP Orthodontia - Child:
CI: 50% AD
FDP Cosmetic Orthodontia - Child:
Not covered
FDP Major Dental Care - Child:
CI: 50% AD
FDP Out of Network Cost Sharing Adult Benefits
FDP Deductible Adult Individual (Out of Network Cost Sharing Adult Benefits):
$50 per adult
FDP MOOP Adult Individual (Out of Network Cost Sharing Adult Benefits):
None
FDP Deductible 2+ Members (Out of Network Cost Sharing Adult Benefits):
$150 maximum
FDP MOOP 2+ Members (Out of Network Cost Sharing Adult Benefits):
None
FDP Office Visit With No Additional Services - Adult (Out of Network Cost Sharing Adult Benefits):
Not covered
FDP Oral Evaluation - Adult (Out of Network Cost Sharing Adult Benefits):
CI: 0% AD
FDP Complete Set of X-Rays - Adult (Out of Network Cost Sharing Adult Benefits):
CI: 0% AD
FDP Prophylaxis - Adult (Out of Network Cost Sharing Adult Benefits):
CI: 0% AD
FDP Topical Fluoride - Adult (Out of Network Cost Sharing Adult Benefits):
Not covered
FDP Polishing - Adult (Out of Network Cost Sharing Adult Benefits):
CI: 0% AD
FDP Sealant (per tooth) - Adult (Out of Network Cost Sharing Adult Benefits):
CI: N/A
FDP Spacers - Adult (Out of Network Cost Sharing Adult Benefits):
Not covered
FDP Simple Extraction - Adult (Out of Network Cost Sharing Adult Benefits):
Not covered
FDP Fillings - Adult (Out of Network Cost Sharing Adult Benefits):
CI: 50% AD
FDP Single Restoration Crowns - Adult (Out of Network Cost Sharing Adult Benefits):
Not covered
FDP Pulp Cap - Adult (Out of Network Cost Sharing Adult Benefits):
Not covered
FDP Bonding - Adult (Out of Network Cost Sharing Adult Benefits):
Not covered
FDP Root Canal - Adult (Out of Network Cost Sharing Adult Benefits):
Not covered
FDP Scaling - Adult (Out of Network Cost Sharing Adult Benefits):
Not covered
FDP Additional Out of Network Cost Sharing Adult Benefits
FDP Gingivectomy or Gingivoplasty - Adult:
Not covered
FDP Gum Surgery - Adult:
Not covered
FDP Tissue Grafting - Adult:
Not covered
FDP Routine Braces - Adult:
Not covered
FDP Partial Dentures - Adult:
Not covered
FDP Complete Dentures - Adult:
Not covered
FDP Dental Implants - Adults:
Not covered
FDP Bridges - Adults:
Not covered
FDP Veneers - Adult:
Not covered
FDP TMJ - Adult:
CI: 50% AD
FDP Out of Network Cost Sharing Pediatric Benefits
FDP Deductible Pediatric Individual (Out of Network Cost Sharing Pediatric Benefits):
$65 per child
FDP MOOP Pediatric Individual (Out of Network Cost Sharing Pediatric Benefits):
None
FDP Deductible Pediatric 2+ Children (Out of Network Cost Sharing Pediatric Benefits):
$195 maximum
FDP MOOP Pediatric 2+ Children (Out of Network Cost Sharing Pediatric Benefits):
None
FDP Dental Check-Up - Child (Out of Network Cost Sharing Pediatric Benefits):
CI: 0% AD
FDP Basic Dental Care - Child (Out of Network Cost Sharing Pediatric Benefits):
CI: 50% AD
FDP Orthodontia - Child (Out of Network Cost Sharing Pediatric Benefits):
CI: 50% AD
FDP Cosmetic Orthodontia - Child (Out of Network Cost Sharing Pediatric Benefits):
Not covered
FDP Major Dental Care - Child (Out of Network Cost Sharing Pediatric Benefits):
CI: 50% AD
FDP Network Information (Family Dental)
FDP Out of Country Coverage:
N
FDP Out of Service Area Coverage:
Y
FDP Out of Service Area Coverage Description:
Nationwide Network
FDP National Network:
Y
FDP Network Name:
Delta Dental PPO
FDP Network URL:
Counties
Albany:
$65.77
Allegany:
$61.58
Bronx:
$90.65
Broome:
$64.68
Cattaraugus:
$61.58
Cayuga:
$64.68
Chautauqua:
$61.58
Chemung:
$64.68
Chenango:
$64.31
Clinton:
$64.31
Columbia:
$65.77
Cortland:
$64.68
Delaware:
$73.56
Dutchess:
$73.56
Erie:
$61.58
Essex:
$64.31
Franklin:
$64.31
Fulton:
$65.77
Genesee:
$61.58
Greene:
$65.77
Hamilton:
$64.31
Herkimer:
$64.31
Jefferson:
$64.31
Kings:
$90.65
Lewis:
$64.31
Livingston:
$63.84
Madison:
$64.31
Monroe:
$63.84
Montgomery:
$65.77
Nassau:
$77.41
New York:
$90.65
Niagara:
$61.58
Oneida:
$64.31
Onondaga:
$64.68
Ontario:
$63.84
Orange:
$73.56
Orleans:
$61.58
Oswego:
$64.31
Otsego:
$64.31
Putnam:
$73.56
Queens:
$90.65
Rensselaer:
$65.77
Richmond:
$90.65
Rockland:
$90.65
Saratoga:
$65.77
Schenectady:
$65.77
Schoharie:
$65.77
Schuyler:
$64.68
Seneca:
$63.84
St Lawrence:
$64.31
Steuben:
$64.68
Suffolk:
$77.41
Sullivan:
$73.56
Tioga:
$64.68
Tompkins:
$64.68
Ulster:
$73.56
Warren:
$65.77
Washington:
$65.77
Wayne:
$63.84
Westchester:
$90.65
Wyoming:
$61.58
Yates:
$63.84