Carondelet Health Network Benefits and Networks
Benefits are based on the dentist you choose
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To search for a network dentist
click here
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Delta Dental PPO™ Network Dentists
Explanation |
Delta Dental Premier® Network Dentists
Explanation |
Out-of-Network Non-Delta Dentist
Explanation |
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Annual Deductible
Individual
Family |
$50
$100 |
Class A:
Preventive & Diagnostic
Routine periodic examinations, x-rays, dental prophylaxis, periodontal cleanings, fluoride and sealants for children |
$100 |
No Deductible |
Class B:
Basic Services (after deductible)
Fillings, periodontics, endodontics (root canal filling) and simple extractions |
80% |
Class C:
Major Services (after deductible)
Bridges, dentures and crowns |
50% |
Class D:
Orthodontic Services (after deductible) |
50% |
Dependent Age |
19 to 25 (full-time students) - end of month |
Annual Maximum Benefits |
$1,250 / Individual |
Ortho Lifetime Maximum |
$1,250 / Individual |
Ortho Age Limit |
Dependent children to age 19 |
(1) Out-of-Network dentists may bill you for the difference between the covered dental expense determined by Delta Dental as the Customary dentists' fees and the dentists' billed amount.
This overview highlights certain features of the Ascension Health dental benefits plan. For full details, please refer to your Summary Plan Description (SPD). If there is a discrepancy between the wording here and the SPD, the document language will govern. Ascension Health reserves the right to amend, modify or terminate the dental plan at any time.