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2016 Dental Benefits Comparison Annual Costs Preferred-provider plan Managed-care plans DeltaCare (Group 3100) Willamette Dental Group Uniform Dental Plan (UDP) (Group 3000 Delta Dental PPO) Deductible $50/person, $150/family None Plan maximum (See specific benefit maximums below.) You pay amounts over $1,750 No general plan maximum For information on specific benefits and exclusions, refer to the dental plan’s certificate of coverage or contact the plan directly. A PPO refers to a preferred-provider organization (network). Benefits Preferred-provider plan Managed-care plans DeltaCare (Group 3100) Willamette Dental Group Uniform Dental Plan (UDP) (Group 3000 Delta Dental PPO) You pay after deductible: You pay: Dentures 50% PPO and out of state; 60% non-PPO $140 for complete upper or lower Root canals (endodontics) 20% PPO and out of state; 30% non-PPO $100 to $150 Nonsurgical TMJ 30% of costs until plan has paid $500 for PPO, out of state, or non-PPO; then any amount over $500 in member’s lifetime DeltaCare: 30% of costs, then any amount after plan has paid $1,000 per year, then any amount over $5,000 in member’s lifetime Willamette Dental Group: Any amount over $1,000 per year and $5,000 in member’s lifetime Oral surgery 20% PPO and out of state; 30% non-PPO $10 to $50 to extract erupted teeth Orthodontia 50% of costs until plan has paid $1,750 for PPO, out of state, or non-PPO, then any amount over $1,750 in member’s lifetime (deductible doesn’t apply) Up to $1,500 copay per case Orthognathic surgery 30% of costs until plan has paid $5,000 for PPO, out of state, or non-PPO; then any amount over $5,000 in member’s lifetime 30% of costs until plan has paid $5,000; then any amount over $5,000 in member’s lifetime Periodontic services (treatment of gum disease) 20% PPO and out of state; 30% non-PPO $15 to $100 Preventive/diagnostic (deductible doesn’t apply) $0 PPO; 10% out of state; 20% non-PPO $0 Restorative crowns 50% PPO and out of state; 60% non-PPO $100 to $175 Restorative fillings 20% PPO and out of state; 30% non-PPO $10 to $50 HCA 50-706 (9/15) To obtain this document in another format (such as Braille or audio), call 1-[PHONE REDACTED]. TTY users may call through the Washington Relay service by dialing 711.