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Wesleyan University – Group # 6507
Delta
Dental Premier
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Calendar Year Deductible |
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Per Person |
$50 |
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Family Aggregate Maximum |
$150 |
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Plan Pays: |
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Preventive & Diagnostic (No Deductible) |
100% |
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Exams, Cleanings, Bitewing X-Rays (2 per calendar year per person) |
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Fluoride Treatment (1 per calendar year for children to age 19) |
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Space Maintainers |
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Remaining Basic (After Deductible) |
80% |
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Fillings, Extractions, Root Canals (Endodontics) |
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Periodontal, Oral Surgery |
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Sealants (To age 14) |
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Crowns & Prosthodontics (After Deductible) |
50% |
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Crowns, Gold Restorations |
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Bridgework, Full & Partial Dentures |
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Repair of Dentures |
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Calendar Year Maximum (Per Person) |
$1,200 |
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Orthodontia (Dependent Children Only) |
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Coinsurance |
50% |
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Lifetime Maximum |
$1,500 |
Dependent
children are covered to age 19 (25 if enrolled as a full time student in an
accredited school or university.)

Delta
Dental has over 2,500+ participating dental offices in Connecticut and 145,000+
participating offices nationwide. You may use any fully licensed dentist under
this plan. Participating dentists will be paid directly by Delta for covered
services. Non-participating dentists will bill you directly, and Delta may make
claim payment directly to you. You will maximize benefits and reduce paperwork
by using a Delta participating dentist.
If you do
not have a dentist, you may obtain a current listing of participating dentists
in any area, by calling 1-800 DELTA OK (1-800-335-8265). Provide your zip code
to the representative and a directory for that area will be mailed to your
home. If you have Internet access, you may also visit our website at
deltadentalnj.com to locate participating dentists.
At the
time of your first appointment, tell the dentist that you are covered under this
program and provide your group number and social security number. Your
dependents, if covered, should provide the employee’s social security number.
Claim questions and
other information needs should be directed to Delta’s benefits services
department at 1-800-452-9310.
This
overview contains a general description of your dental care program for your use
as a convenient reference. Complete details of your program appear in the group
contract between your plan sponsor and Delta Dental Plan of New Jersey, Inc.
which governs the benefits and operation of your program. The group contract
would control if there should be any inconsistency or difference between its
provisions and the information in this overview.

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