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Dental Benefits

Summary of Dental Benefits

Effective January 1, 2019

Dental Benefits		Delta Dental PPO Provider	Out of Network Provider

Preventative (Routine)		100%	50% of R&C

Calendar Year Maximum		$1500 Orthodontia not included

Deductible

Restorative/Replacement		$50 for Restorative/Replacement

Orthodontia (dependent children only)	50% to $2000 lifetime maximum per dependent child

How to file a Dental Claim

Send all dental claims to:

Delta Dental of Illinois

P.O. Box 5402, Lisle, IL 60532

Inform your Dentist to refer to Group #20126

For additional Dental Benefit information, please refer to

pages 16-18 of your 2019 Summary Plan Description Book

Click here to download a copy of our
2019 Summary Plan Description Book