Delta PPO

Dental Services Paid by Delta

Diagnostic 90%
Preventive
Oral Surgery
90%
80%
Fine Print
Endodontic 70% Complete
Orthodontics 50%
TMJ 50% definition of
Delta Dental Benefits Periodontal
Major Restorative
50%
50% benefits,
Maximums: $2000 per person per calendar year. limitations &
Orthodontics has a separate maximum of $1250 lifetime
exclusions is
per patient. Deductible: $50 per person per calendar year.
Maximum of $150 per family per calendar year. Does not contained in the
apply to Diagnostic and Preventative care.
Group Dental
Dependent children are covered to age 19. Full-time Service Contract.
dependent students enrolled in bona fide institution of
higher education are covered to age 23. Mentally and This explanation is
physically disabled dependent children are eligible for
dental care under the program regardless of age. informational only.
Orthodontics is only a benefit for dependent children to age
19. Benefits subject to

Coverage is available for qualified Domestic Partners.

all terms &
Call for more info on enrolling Domestic Partners. Please conditions of the
Two Plans. Your Choice. note: There is a 60-day waiting period for all new hires.
Group Dental
DeltaPPO Option (PPO) is a discounted fee- 2009 Monthly Payments
Individual $31.36 Service Contract.
for-service, managed-cost dental plan that
allows you the freedom to choose any dentist 2-Person $81.22
for treatment, (but you will receive the Family $104.40
greatest benefit from a dentist participating in For more
Delta’s preferred provider network.) The Delta
Premier program has the nation's largest Delta Care USA information
dental network, with more than three out of
every four of the country's dentists Dental Services Paid by Delta Please contact Eric
participating. Delta Premier provides a level of
enrollee protection that is unmatched. Periodic oral evaluation No cost Laughlin at (800)
Diagnostic Casts No cost
515-5012 ext. 128
Cleaning (1 every 6 months) No cost
DeltaCare USA Option (HMO) Delta Care USA Replacement Crown $10 or visit
is Delta Dental’s national Dental Health Crown (Resin, Indirect) $110
Maintenance Organization. Subscribers select Root Canal (Molar) $180 www.ccsnys.org
from a panel of primary care dentists. These
dentists manage subscriber’s comprehensive The services above represent a sample of frequently used
dental needs including referrals to specialists, services. For full details please contact NYCON.
which earns each dentist a monthly capitation
amount. Delta Care USA is the choice for No Deductible. Maximums: Please see contract pricing
groups seeking lower costs, an emphasis on sheet for details. Maximums may apply to specific areas.
prevention and access to a pre-selected
network of dentists. Dependent children are covered to age 19. Full-time
dependent students enrolled in bona fide institution of
Eligibility. Staff of current NYCON members higher education are covered to age 23. Mentally and
physically disabled dependent children are eligible for
who work at least 20 hours per week are dental care under the program regardless of age.
eligible to enroll effective the first of any month Orthodontics is only a benefit for dependent children to age
after the signing of a group contract with the 19.
New York Council of Nonprofits, Inc. NYCON
Coverage is available for qualified Domestic Partners.
will provide identification cards for this plan. Call for more info on enrolling Domestic Partners.
Subscribers may also use their social security
number and the group number indicated as 2009 Monthly Payments
proof of their enrollment and benefits. Individual $30.60
2-Person $46.34
If an eligible member does not enroll eligible dependents Family $63.73
Contact Eric Laughlin, Marketing Associate
in the plan at the time of enrollment, they will need to wait until
1(800) 515-5012 ext. 128
the next open enrollment date to add them unless there is a
Email: elaughlin@councilservicesplus.com
qualifying event. There will be an open enrollment period in