Plan Benefit Highlights for: Gettysburg College
(High Option)
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Eligibility |
For eligibility details, refer to the plan's Evidence/Certificate of Coverage (on file with your benefits administrator, plan sponsor or employer). |
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Deductibles |
None |
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Maximums D & P counts toward maximum? |
$1,200 per person each calendar year |
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Yes |
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Waiting Period(s) |
Basic Services None |
Major Services None |
Prosthodontics None |
Orthodontics None |
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Benefits and Covered Services* |
Delta Dental PPO dentists** |
Non-Delta Dental PPO dentists** |
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Diagnostic & Preventive Services (D & P) Exams, cleanings, x-rays and sealants |
100% |
100% |
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Basic Services Fillings and posterior composites |
80% |
80% |
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Endodontics (root canals) Covered Under Basic Services |
80% |
80% |
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Periodontics (gum treatment) Covered Under Basic Services |
80% |
80% |
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Oral Surgery Covered Under Basic Services |
80% |
80% |
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Major Services Crowns, inlays, onlays and cast restorations |
50% |
50% |
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Prosthodontics Bridges, dentures and implants |
50% |
50% |
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Implant Maximums |
$1,200 Lifetime |
$1,200 Lifetime |
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Orthodontic Benefits Dependent children to age 19 |
50% |
50% |
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Orthodontic Maximums |
$1,200 Lifetime |
$1,200 Lifetime |
Limitations or waiting periods may apply for some benefits; some services may be excluded from your plan. Reimbursement is based on Delta Dental maximum contract allowances and not necessarily each dentist’s submitted fees.
Reimbursement is based on PPO contracted fees for PPO dentists, Premier contracted fees for Premier dentists and Premier contracted fees for nonDelta Dental dentists.
Delta Dental of Pennsylvania
One Delta Drive
Mechanicsburg, PA 17055
Customer Service
800-932-0783
Claims Address
P.O. Box 2105
Mechanicsburg, PA 17055-6999
This benefit information is not intended or designed to replace or serve as the plan’s Evidence of Coverage or Summary Plan Description. If you have specific questions regarding the benefits, limitations or exclusions for your plan, please consult your company’s benefits representative.
Revised 9/14/2022