DENTAL

Delta Dental– Group #1170

Hudson City Schools District offers two types of dental plans – the Dental Plan High or the Dental Plan Low.

Please see the below breakdown of each plan.

	Delta Dental PPO Dentist Plan Pays	Delta Dental Premier Dentist Plan Pays	Nonparticipating Dentist Play Pays
Diagnostic & Preventive
Diagnostic and Preventive Services – exams, cleanings, fluoride, and space maintainers	100%	100%	100%
Emergency Palliative Treatment – to temporarily relieve pain	100%	100%	100%
Basic Services
Minor Restorative Services – fillings and crown repair	80%	80%	80%
Endodontic Services – root canals	80%	80%	80%
Other Basic Services	80%	80%	80%
Major Services
Major Restorative Services – crowns	60%	60%	60%
Prosthodontic Services – bridges, implants, dentures and crowns over implants	60%	60%	60%
Orthodontic Services
Orthodontic Services – braces No Age Limit	60%	60%	60%

This is just a “benefits at a glance” please refer to the full Summary of Benefits for more.

	Delta Dental PPO Dentist Plan Pays	Delta Dental Premier Dentist Plan Pays	Nonparticipating Dentist Play Pays
Diagnostic & Preventive
Diagnostic and Preventive Services – exams, cleanings, fluoride, and space maintainers	100%	100%	100%
Emergency Palliative Treatment – to temporarily relieve pain	100%	100%	100%
Basic Services
Minor Restorative Services – fillings and crown repair	50%	50%	50%
Endodontic Services – root canals	50%	50%	50%
Other Basic Services	50%	50%	50%
Major Services
Major Restorative Services – crowns	25%	25%	25%
Prosthodontic Services – bridges, implants, dentures and crowns over implants	25%	25%	25%
Orthodontic Services
Orthodontic Services – braces No Age Limit	50%	50%	50%

This is just a “benefits at a glance” please refer to the full Summary of Benefits for more.