USC Verdugo Hills PPO dental plan

The USC Verdugo Hills PPO dental insurance plan is administered by Delta Dental.

DENTAL
 

BENEFIT

In‐Network

(Delta Dental PPO Provider)

Out‐of‐Network

(Non‐PPO Provider)

 

Deductible: Individual / Family

 

$50 / $150

 

Maximum

$1,500 per person per calendar year

(maximum payments to an out‐of‐network provider: $1,000)

Waiting Periods None
Diagnostic & Preventive Services

ž Routine Oral Exams

ž Cleaning / Scaling

ž Bite‐wing and Full‐mouth X‐rays

ž Space Maintainers

ž Fluoride Treatment

 

 

 

The Plan pays 100% (deductible waived)

 

The Plan pays 80% of the lesser of the Fee Actually Charged, or the fee that satisfies the majority of Delta Dental Dentists

(deductible waived)

 

Basic Services

ž Oral Surgery

ž Extractions

ž Endodontics

ž Periodontics

ž Sealants

(for children under age 16)

ž Anesthesia

 

 

 

 

 

The Plan pays 80%

 

 

 

The Plan pays 80% of the lesser of the Fee Actually Charged, or the fee that satisfies the majority of Delta Dental Dentists

Major Services

ž Crowns

ž Inlays, Onlays, and Cast Restorations

ž Bridges and dentures

 

 

The Plan pays 50%

The Plan pays 50% of the lesser of the Fee Actually Charged, or the fee that satisfies the majority of Delta Dental Dentists
 

 

 

Orthodontic Benefits (children only)

 

 

 

The Plan pays 50%

 

The Plan pays 50% of the lesser of the Fee Actually Charged, or the fee that satisfies the majority of Delta Dental Dentists

 

Orthodontic Lifetime Maximum

 

$1,000 per person

Delta Dental | www.deltadentalins.com

(800) 765-6003