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Delta PPO plus Premier Network

Dental Services Paid by Delta

Diagnostic 100%
Preventive
Oral Surgery
100%
80%
Fine Print

Delta Dental
Endodontic 70% Complete
Orthodontics 50%
TMJ 50% definition of
Periodontal 50%

Benefits
Major Restorative 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
All dependents are covered to age 29. Mentally and Service Contract.
physically disabled dependent children are eligible for
dental care under the program regardless of age. This explanation is
Orthodontics is only a benefit for dependent children to age
19. informational only.
Coverage is available for qualified Domestic Partners. Benefits subject to
Call for more info on enrolling Domestic Partners.
all terms &
conditions of the
2011 Monthly Payments
Two Plans. Your Choice. Individual $31.40 Group Dental
DeltaPPO Option (PPO) is a discounted fee- 2-Person $83.68 Service Contract.
for-service, managed-cost dental plan that Family $107.98
allows you the freedom to choose any dentist
for treatment, but you will receive the
greatest benefit from a dentist participating in For more
Delta’s Premier provider network. The Delta
Premier program has the nation's largest Delta Care USA information
dental network, with more than three out of Dental Services Paid by Delta
every four of the country's dentists Please contact
participating. Delta Premier provides a level of Periodic oral evaluation No cost Kristie Hood at
enrollee protection that is unmatched. Diagnostic Casts No cost
(800) 515-5012
Cleaning (1 every 6 months) No cost
DeltaCare USA Option (HMO) Delta Care USA Replacement Crown $10 ext. 129
is Delta Dental’s national Dental Health Crown (Resin, Indirect) $110
or visit
Maintenance Organization. Subscribers select Root Canal (Molar) $180
from a panel of primary care dentists. These www.nycon.org
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. and click on
which earns each dentist a monthly capitation Helping Nonprofits
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. and Employee
prevention and access to a pre-selected All dependents are covered to age 29. Mentally and Benefits.
network of dentists. physically disabled dependent children are eligible for
dental care under the program regardless of age.
Eligibility. Staff of current NYCON members Orthodontics is a benefit for adults and dependent children.
who work at least 20 hours per week are
eligible to enroll effective the first of any month Coverage is available for qualified Domestic Partners.
Call for more info on enrolling Domestic Partners.
after the signing of a group contract with
NYCON. ID cards can be printed after each 2011 Monthly Payments
member registers an account online.
Individual $31.11
Subscribers may also use their social security
2-Person $48.01
number and the group number indicated as
Family $66.67
proof of their enrollment and benefits.

Contact
If an eligible Kristie
member Hood,
does Marketingeligible
not enroll Associate
dependents
1(800)
in the plan at the time of515-5012
enrollment,ext.
they129
will need to wait until
the nextEmail: khood@councilservicesplus.com
open enrollment date to add them unless there is a
qualifying event. There will be an open enrollment period in

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