Dental Benefits

Download Dental Benefits Summary
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Claims Administrator: Delta Dental | Group Number: PA9343

Website: https://www1.deltadentalins.com/erie | Phone: 1-800-932-0783

  • Provides preventive, diagnostic, restorative and orthodontic dental treatment benefits for you and your covered dependents.
  • Plan ID cards are not issued; use your Social Security number for member identification.

Summary of Dental Benefits

Annual Deductible

Benefits
In-Network Delta Premier and Delta Preferred Dentists
Out-of-Network
Benefits
In-Network Delta Premier and Delta Preferred Dentists
When using an in-network provider, deductible does not apply.
Out-of-Network
Applies to basic and major restorative services only. Deductible must be satisfied before dental benefits will pay.
Benefits

Individual

In-Network Delta Premier and Delta Preferred Dentists

$0

Out-of-Network

$25

Benefits

Family

In-Network Delta Premier and Delta Preferred Dentists

$0

Out-of-Network

$75

Annual Maximum Benefits (Does not apply to orthodontia)

In-Network Delta Premier and Delta Preferred Dentists
Out-of-Network
In-Network Delta Premier and Delta Preferred Dentists
$2,000 per person (Combined limit not to exceed $2,000 per person per calendar year)
Out-of-Network
$1,000 per person (Combined limit not to exceed $2,000 per person per calendar year)

Preventive & Diagnostic Services[1]

Benefits
In-Network Delta Premier and Delta Preferred Dentists
Out-of-Network
Benefits
  • Oral examinations
  • X-rays
  • Emergency palliative treatment
  • Prophylaxis
  • Fluoride for children under 19
  • Space maintainers
In-Network Delta Premier and Delta Preferred Dentists
Plan pays in full (subject to annual maximum)
Out-of-Network
Plan pays in full (subject to annual maximum)

Basic Restorative Services[1]

Benefits
In-Network Delta Premier and Delta Preferred Dentists
Out-of-Network
Benefits
  • Fillings
  • Endodontics
  • Periodontics
  • Denture repairs & relining
  • Crown & bridge repairs
  • Oral surgery
  • Anesthetics
In-Network Delta Premier and Delta Preferred Dentists
Plan pays in full (subject to annual maximum)
Out-of-Network
Plan pays 75% (subject to deductible and annual maximum)

Major Restorative Services[1]

Benefits
In-Network Delta Premier and Delta Preferred Dentists
Out-of-Network
Benefits
  • Inlays, onlays, & crowns
  • Prosthodontics
  • Dentures & partials
  • Implants
In-Network Delta Premier and Delta Preferred Dentists
Plan pays 50% (subject to annual maximum)
Out-of-Network
Plan pays 50% (subject to deductible and annual maximum)

Orthodontia Services[1]

Benefits
In-Network Delta Premier and Delta Preferred Dentists
Out-of-Network
Benefits
Annual maximum does not apply
In-Network Delta Premier and Delta Preferred Dentists
Plan pays 50%; Lifetime maximum benefits: $3,000 per person
Out-of-Network
Plan pays 50%; Lifetime maximum benefits: $3,000 per person
  1. 1. 
    Refer to the Benefits Summary Plan Descriptions for details on in- and out-of-network benefits and exclusions.
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