SOLO: Optional Dental Benefits from Delta Dental: Compare Plans
Great coverage
You can choose from three plans that cover a wide range of services you may need—from routine services like oral exams, cleanings, and X-rays to more complex (and expensive) services like bridges, crowns, and dentures.
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HAP SOLO High
Delta Dental PPO
(Point-of-Service)
Plan Pays* |
HAP SOLO Medium
Delta Dental PPO
(Point-of-Service)
Plan Pays* |
HAP SOLO Low
Delta Dental PPO
(Standard)
Plan Pays* |
| Delta Dental PPO Dentist |
Delta Dental Premier Dentist |
Non-par Dentist |
Delta Dental PPO Dentist |
Delta Dental Premier Dentist |
Non-par Dentist |
Delta Dental PPO Dentist |
Non-par Dentist** |
| CLASS I |
Diagnostic and Preventive Services
Used to diagnose and/or prevent dental abnormalities or disease (includes exams, cleanings, and fluoride treatments) |
100% |
100% |
100% |
100% |
50% |
50% |
100% |
0% |
Emergency Palliative Treatment
Used to temporarily relieve pain |
100% |
100% |
100% |
100% |
50% |
50% |
100% |
0% |
Radiographs
X-rays |
100% |
100% |
100% |
100% |
50% |
50% |
100% |
0% |
| CLASS II |
Oral Surgery
Extractions and dental surgery, including preoperative and postoperative care |
50% |
50% |
50% |
50% |
50% |
50% |
50% |
0% |
Minor Restorative Services
Used to repair teeth damaged by disease or injury (for example, fillings) |
50% |
50% |
50% |
50% |
50% |
50% |
50% |
0% |
Periodontics
Used to treat diseases of the gums and supporting structures of the teeth |
50% |
50% |
50% |
50% |
50% |
50% |
50% |
0% |
Endodontics
Used to treat teeth with diseased or damaged nerves (for example, root canals) |
50% |
50% |
50% |
50% |
50% |
50% |
50% |
0% |
| CLASS III*** |
Major Restorative Services
Used when teeth cannot be restored with another filling material (for example, crowns) |
50% |
50% |
50% |
25% |
25% |
25% |
N/A |
N/A |
Prosthodontics
Used to replace missing natural teeth (for example, bridges, endosteal implants, and dentures) |
50% |
50% |
50% |
25% |
25% |
25% |
N/A |
N/A |
Maximum Payment
The per person total per calendar year for Class I, Class II and Class III Benefits |
$1,500 |
$1,000 |
$1,000 |
$1,250 |
$750 |
$750 |
$1,000 |
$1,000 |
Deductible
$50 per person total per calendar year on Class II and Class III Benefits. The deductible does not apply to Class I Benefits. |
* Coverage levels are based on the following: Delta Dental PPO—based on dentist’s submitted fee or the amount in the local Delta Dental’s PPO dentist fee schedule, whichever is less; Delta Dental Premier—based on dentist’s submitted fee or the maximum approved fee for Delta Dental’s Premier dentist fee schedule, whichever is less; and Nonparticipating—based on dentist’s submitted fee or Delta Dental’s nonparticipating dentist fee, whichever is less.
** There is no out-of-network coverage except for certain emergency services associated with the emergency treatment of dental pain or a problem-focused exam.
*** Class III Benefits are not applicable to the HAP SOLO Low—Delta Dental PPO (Standard) Plan
Delta Dental Plan of Michigan, Inc. • P.O. Box 30416, Lansing, MI 48909
Customer Service (800) 971-4108 • www.deltadentalmi.com
This document is intended as a supplement to your Dental Care Certificate and Summary of Dental Plan Benefits. Please refer to your certificate and summary for costs and complete details of coverage, including policy exclusions and limitations, or call us at (800) 971-4108.
Underwritten by Renaissance Life & Health Insurance Company of America. This product is available to Michigan residents only.
All Content ©2010 Health Alliance Plan
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