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:
Parent and child only
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:
$49.90
Allegany:
$46.72
Bronx:
$68.77
Broome:
$49.07
Cattaraugus:
$46.72
Cayuga:
$49.07
Chautauqua:
$46.72
Chemung:
$49.07
Chenango:
$48.79
Clinton:
$48.79
Columbia:
$49.90
Cortland:
$49.07
Delaware:
$55.81
Dutchess:
$55.81
Erie:
$46.72
Essex:
$48.79
Franklin:
$48.79
Fulton:
$49.90
Genesee:
$46.72
Greene:
$49.90
Hamilton:
$48.79
Herkimer:
$48.79
Jefferson:
$48.79
Kings:
$68.77
Lewis:
$48.79
Livingston:
$48.43
Madison:
$48.79
Monroe:
$48.43
Montgomery:
$49.90
Nassau:
$58.73
New York:
$68.77
Niagara:
$46.72
Oneida:
$48.79
Onondaga:
$49.07
Ontario:
$48.43
Orange:
$55.81
Orleans:
$46.72
Oswego:
$48.79
Otsego:
$48.79
Putnam:
$55.81
Queens:
$68.77
Rensselaer:
$49.90
Richmond:
$68.77
Rockland:
$68.77
Saratoga:
$49.90
Schenectady:
$49.90
Schoharie:
$49.90
Schuyler:
$49.07
Seneca:
$48.43
St Lawrence:
$48.79
Steuben:
$49.07
Suffolk:
$58.73
Sullivan:
$55.81
Tioga:
$49.07
Tompkins:
$49.07
Ulster:
$55.81
Warren:
$49.90
Washington:
$49.90
Wayne:
$48.43
Westchester:
$68.77
Wyoming:
$46.72
Yates:
$48.43