Delta Dental of Tennessee
Dental Benefit Highlights for
Hamblen County Department of Education #7551
January 1, 2019 7551-0010
Delta Dental PPO (Standard)
Coverage effective January 1, 2019
Delta Dental
PPO Dentist
Delta Dental
Premier
Dentist
Nonparticipating
Dentist
Plan Pays Plan Pays* Plan Pays*
Diagnostic & Preventive
Diagnostic and Preventive Services -
exams, cleanings, fluoride, and space
maintainers
100% 80% 80%
Sealants - to prevent decay of permanent
teeth
100% 80% 80%
Bitewing Radiographs - bitewing X-rays 100% 80% 80%
Basic Services
Emergency Palliative Treatment - to
temporarily relieve pain
80% 60% 60%
Brush Biopsy - to detect oral cancer 80% 60% 60%
All Other Radiographs - other X-rays 80% 60% 60%
Minor Restorative Services - fillings 80% 60% 60%
Simple Extractions - non-surgical removal
of teeth
80% 60% 60%
Other Oral Surgery - dental surgery other
than extractions
80% 60% 60%
Major Services
Crown Repair - to individual crowns 50% 50% 50%
Endodontic Services - root canals 50% 50% 50%
Periodontic Services - to treat gum disease 50% 50% 50%
Surgical Extractions - surgical removal of
teeth
50% 50% 50%
Major Restorative Services - crowns 50% 50% 50%
Other Basic Services - misc. services 50% 50% 50%
Relines and Repairs - to bridges, implants,
and dentures
50% 50% 50%
Prosthodontic Services - bridges, implants,
and dentures
50% 50% 50%
Orthodontic Services
Orthodontic Services - braces 50% 50% 50%
Orthodontic Age Limit - to the end of
the month of
age 19
to the end of
the month of
age 19
to the end of
the month of
age 19
* When you receive services from a Delta Dental Premier or Nonparticipating Dentist, the percentages
in this column indicate the portion of Delta Dental's PPO Dentist Schedule that will be paid for those
services. This amount may be less than what the dentist charges or Delta Dental approves and you
are responsible for that difference.
Maximum Payment – $1,500 per person total per Benefit Year on harmful habits appliances and
all general services, except cephalometric film and photos. $1,250 per person total per lifetime
on cephalometric film, photos, and orthodontic services, excluding harmful habits appliances.
Deductible –
Delta Dental PPO Dentist - None.
Delta Dental Premier Dentist or Nonparticipating Dentist - $100 Deductible per person total
per Benefit Year limited to a maximum Deductible of $300 per family per Benefit Year. The
Deductible does not apply to oral exams, preventive services, bitewing X-rays, brush biopsy,
sealants, and orthodontic services.
Welcome to Tennessee's largest dental
benefits family!
As a member of Delta Dental of Tennessee,
you have access to the nation's largest dental
networks: Delta Dental PPO and Delta Dental
Premier.
 It's easy to find a dentist! Four out of five
dentists nationwide participate in our network.
 You have superior access to care and fee
savings because of our agreements with
participating dentists.
 Our dentists cannot balance bill you, which
means more money in your pocket!
 No troublesome paperwork! Network
dentists will fill out and file your claims.
 Pay only your copayments and/or
deductibles when you receive care from PPO
dentists -- there are no hidden fees.
 Because payment is based on the PPO
Dentist Schedule, you may have to pay more
for services from our Premier Dentists (up to
our Maximum Approved Fee).
 You can still visit nonparticipating dentists,
but you may be billed the full amount at the
time of service and then have to wait to be
reimbursed.
Quality Dental Program
With our quick and accurate claims
processing, we pay more than 90% of claims
in 10 days or less. Delta Dental also offers
world-class customer service from our
dedicated call center.
Online Access
Our online Consumer Toolkit lets you access
your dental plan securely over the Internet. You
can find a dentist, check benefits, select
paperless notices, review claims and amounts
used toward maximums, print ID cards, and
more -- all at your own convenience.
A Healthy Smile
Keep your smile healthy with dental benefits
from Delta Dental. Your smile is a good indicator
of your health. Did you know that your dentist
can detect up to 120 different diseases, including
diabetes and heart disease? Early detection is
one of the best ways to prevent further
complications.
Questions?
If you have questions, please call our
Customer Service team at 800-223-3104 or
look online at
https://www.DeltaDentalTN.com.
January 1, 2019 7551-0010
Benefit Waiting Period – There is a 365-day waiting period for certain services. Major
Restorative Services, Implant Repair, Prosthodontic Services, and Orthodontic Services will not be
covered until after a person is enrolled in the dental plan for 365 consecutive days.
Note - This document is only intended to provide a brief description of your benefits. Please refer to your
Certificate and summary for a complete description of benefits, exclusions, and limitations.