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IBEW Local #1253

Group #: 6563

Your Northeast Delta Dental program includes all of the following coverage categories. Please refer to your benefit booklet

for complete benefit information. This chart is provided for summary purposes only. In the event of a conflict or

discrepancy between the chart and either the group contract or the benefit booklet, the contract or benefit booklet will

prevail.

Type Diagnostic & Preventive

(Referred to as

Coverage A)

Basic Restorative

(Referred to as

Coverage B)

Major Restorative

(Referred to as

Coverage C)

Orthodontics

(Referred to as

Coverage D)

Covered

Services

DIAGNOSTIC:

Evaluations once in a 6-

month period

X-Rays (complete series

or panoramic film) once

in a 3-year period,

bitewing X-Rays once

each 12-month period, XRays

of individual teeth

as necessary

PREVENTIVE:

Cleanings once in a 6-

month period

Fluoride once in a 12-

month period to age 19

Space maintainers to

age 16

Sealant application to

permanent molars, once

in a lifetime per tooth, for

children to age 15

RESTORATIVE:

Amalgam fillings

Composite (white) fillings

(anterior teeth only)

ORAL SURGERY:

Surgical and routine

extractions

ENDODONTICS:

Root canal therapy

PERIODONTICS:

Periodontal Cleaning

(Maintenance procedures)

Note: Only one cleaning is

covered in a 6-month period.

This can be a routine

(Coverage A) or a periodontal

(Coverage B), but not both.

Treatment of gum disease

DENTURE REPAIR:

Repair of removable denture

to its original condition

EMERGENCY PALLIATIVE

TREATMENT

PROSTHODONTICS:

Removable and fixed

partial dentures

(bridge); complete

dentures

Rebase and reline

(dentures)

Crowns

Onlays

ORTHODONTICS:

Correction of malposed

(crooked) teeth for

adults and dependent

children to age 19

Waiting

Period

None 6 Months 12 Months 24 Months

Deductible No Deductible $100/$300 Lifetime Deductible

Per Person/Family

No Deductible

Coinsurance

Delta Dental Pays

100%

After Waiting Period

And Deductible,

Delta Dental Pays

80%

After Waiting Period

And Deductible,

Delta Dental Pays

50%

After Waiting Period,

Delta Dental Pays

50%

Maximum Coverage A, B and C Combined Calendar Year Maximum

(January 1 – December 31): $1,000 Per Person

Lifetime Maximum:

$1,000 Per Person

Benefit percentages shown are based upon the actual charge submitted to a maximum of the participating dentist’s

approved fees, or Delta Dental’s allowance for nonparticipating dentists.