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Priority Health - 2021 EHB ONLY Flipbook PDF
Priority Health - 2021 EHB ONLY
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Delta Dental Plan of Michigan, Inc. Priority Health 2021 Certified EHB Dental Benefit Plans Delta Dental PPO SM (Point-of-Service)
The following benefits include the Certified EHB Dental Benefits covered by Delta Dental of Michigan.
Plan A 6XXX High Pediatric Dental Plan
Plan B 5XXX Low Pediatric Dental Plan
Plan Pays
Delta Dental Premier / Nonparticipating Dentist Plan Pays
Delta Dental PPO Dentist Plan Pays
Delta Dental Premier / Nonparticipating Dentist Plan Pays
100%
100%
100%
80%
Brush Biopsy - to detect oral cancer Emergency Palliative Treatment - to temporarily relieve pain
100%
100%
100%
80%
100%
100%
100%
80%
Radiographs - X-rays
100%
100%
100%
80%
Sealants - to prevent decay of permanent teeth
100%
100%
100%
80%
Minor Restorative Services - fillings Oral Surgery Services - extractions and dental surgery
80%
60%
50%
50%
80%
60%
50%
50%
Endodontic Services - root canals
80%
60%
50%
50%
Periodontic Services - to treat gum disease
80%
60%
50%
50%
Relines and Repairs - prosthetic appliances
80%
60%
50%
50%
Other Basic Services - misc. services
80%
60%
50%
50%
50%
50%
50%
50%
50%
50%
50%
50%
Please mark the plan of your choice. Effective 1/1/2021 – 12/31/2021
Diagnostic & Preventive Diagnostic and Preventive Services - exams, cleanings, fluoride, and space maintainers
Delta Dental PPO Dentist
Basic Services
Major Services Prosthodontic Services – bridges, dentures, and crowns over implants Major Restorative Services – crowns Maximum Payment – per person per calendar year on Diagnostic & Preventive, Basic Services and Major Services Deductible – per person / per family per calendar year. The Deductible does not apply to exams, cleanings, fluoride, space maintainers, emergency palliative treatment, brush biopsy, and sealants. Rates per subscriber per month – 1 Child 2 Children 3+ Children
None
None
None
$25 / $75
$33.38 $66.76 $100.14
$28.26 $56.52 $84.78
NOTE: For all EHB Covered Services provided by a PPO or Premier Dentist, the maximum out-of-pocket payments are $350 per calendar year for one person age 18 and under, or $700 per calendar year per family with two or more people age 18 and under. 1 2 3
Above plan designs assume Delta Dental’s standard limitations unless otherwise noted. These rates are valid through December 31, 2021 for a one year contract. Rates do not include any applicable claims taxes.
An individual will be considered age 18 and under until the end of the Benefit Year in which the individual attains the age of 19. 9/2020