Delta Airlines 2011 Annual Report Download - page 134
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Exhibit B
Comprehensive Dental Option Overview
The dental option described below is a traditional dental option which provides comprehensive coverage for preventive services, basic restorative services,
major restorative services, and orthodontic services.
DABHP Comprehensive Dental Option Benefits
2012 Dental Benefit Coverage
Annual Maximum Benefit $2,000 per person
Annual Deductible $60 Individual/$240 Family
Preventive Services 100% of Plan Payment Obligation;
not subject to the deductible
Basic Restorative Services
(Such as fillings, extractions, root canals, periodontal procedures)
70% of Plan Payment Obligation after deductible
Major Restorative Services
(Such as crowns, bridges, implants, inlays, onlays)
50% of Plan Payment Obligation after deductible
Dental Oral Surgeries
Simple extractions and other oral surgery procedures
70% of Plan Payment Obligation after deductible
Dental Oral Surgeries
Complex surgical extractions (ADA Codes: 07220, 07230, 07240,
07241, 07951)
50% of Plan Payment Obligation after deductible
Prosthetic Repairs and Adjustments
Denture adjustments and repairs, bridge repair
70% of Plan Payment Obligation after deductible
Prosthetics
Dentures (full and partial), bridges, dental implants and covered
implant-related services
50% of Plan Payment Obligation after deductible
Orthodontia Services 50% of Plan Payment Obligation after deductible
Lifetime Orthodontia Maximum Benefit $2,000 per person
Lifetime TMJ Maximum Benefit $500 per person
*