Plan
Plan Name:
Delta Dental PPO Basic Plan for Families NS OON Dep 25 Family Dental
Issuer Name:
Delta Dental of New York, Inc
HIOS ID:
10345NY0010006
Annual Benefit Maximum:
$1,000
Plan Brochure Link:
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:
No
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
Lifetime Benefit Maximum:
$300 lifetime maximum for adult TMJ services
Coverage Level:
Individual
Benefits Excluded from In Network MOOP:
N/A
Benefits Excluded from Out of Network MOOP:
N/A
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:
CI: 50% Coins AD
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:
N/A
FDP Deductible 2+ Adult Members:
$150
FDP MOOP 2+ Members:
N/A
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% Coins AD
FDP In Network Cost Sharing Pediatric Benefits
FDP Deductible Pediatric Individual:
$65
FDP MOOP Pediatric Individual:
$425
FDP Deductible Pediatric 2+ Children:
$195
FDP MOOP Pediatric 2+ Children:
$850
FDP Dental Check-Up - Child:
CI: 0% AD
FDP Basic Dental Care - Child:
CI: 50% Coins AD
FDP Orthodontia - Child:
CI: 50% Coins AD
FDP Cosmetic Orthodontia - Child:
Not covered
FDP Major Dental Care - Child:
CI: 50% Coins AD
FDP Out of Network Cost Sharing Adult Benefits
FDP Deductible Adult Individual (Out of Network Cost Sharing Adult Benefits):
$50
FDP MOOP Adult Individual (Out of Network Cost Sharing Adult Benefits):
None
FDP Deductible 2+ Members (Out of Network Cost Sharing Adult Benefits):
$150
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):
Not covered
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% Coins 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% Coins 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% Coins AD
FDP Orthodontia - Child (Out of Network Cost Sharing Pediatric Benefits):
CI: 50% Coins 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% Coins 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 Individual
FDP Network URL:
Counties
Albany:
$17.94
Allegany:
$16.79
Bronx:
$24.72
Broome:
$17.64
Cattaraugus:
$16.79
Cayuga:
$17.64
Chautauqua:
$16.79
Chemung:
$17.64
Chenango:
$17.53
Clinton:
$17.53
Columbia:
$17.94
Cortland:
$17.64
Delaware:
$20.06
Dutchess:
$20.06
Erie:
$16.79
Essex:
$17.53
Franklin:
$17.53
Fulton:
$17.94
Genesee:
$16.79
Greene:
$17.94
Hamilton:
$17.53
Herkimer:
$17.53
Jefferson:
$17.53
Kings:
$24.72
Lewis:
$17.53
Livingston:
$17.41
Madison:
$17.53
Monroe:
$17.41
Montgomery:
$17.94
Nassau:
$21.11
New York:
$24.72
Niagara:
$16.79
Oneida:
$17.53
Onondaga:
$17.64
Ontario:
$17.41
Orange:
$20.06
Orleans:
$16.79
Oswego:
$17.53
Otsego:
$17.53
Putnam:
$20.06
Queens:
$24.72
Rensselaer:
$17.94
Richmond:
$24.72
Rockland:
$24.72
Saratoga:
$17.94
Schenectady:
$17.94
Schoharie:
$17.94
Schuyler:
$17.64
Seneca:
$17.41
St Lawrence:
$17.53
Steuben:
$17.64
Suffolk:
$21.11
Sullivan:
$20.06
Tioga:
$17.64
Tompkins:
$17.64
Ulster:
$20.06
Warren:
$17.94
Washington:
$17.94
Wayne:
$17.41
Westchester:
$24.72
Wyoming:
$16.79
Yates:
$17.41