In-Home Supportive Services Public Authority of Marin

Benefits	Delta Dental Co-Pay	Delta Dental Co-Pay	Pacific Union Dental Co-Pay
	PPO DENTIST	NON-PPO DENTIST	PUD DENTISTS ONLY
Cleaning, X-Ray and Exam	No Cost	No Cost	No Cost
Simple Filling	20%	20%	No Cost
Crown and Resin Lab	40%	50%	$42 - 73
Endodontics	20%	20%	$0 - 96
Periodontics	20%	20%	No Cost
Orthodontics	50% $1,000 maximum lifetime	50% $1,000 maximum lifetime	$350 to start $750 $150 month for 10 months $2,250 one time for full banded 2 years
Prosthodontics	40%	50%	$5 - 93
Root Canal and Molar	20%	20%	$0 - 96
Maximum Benefit Paid Per Year	$1,000	$1,000	No limit
Deductible	$50 Annual. Waived on diagnostic and preventive benefits.	$50 Annual. Waived on diagnostic and preventive benefits.	None.

Los Beneficios	Delta Dental Gasto compartido que Ud. paga	Delta Dental Gasto compartido que Ud. paga	Pacific Union Dental Gasto compartido que Ud. paga
	Dentista de DPO	Dentista que no está con DPO
Limpieza, radiografía, y examen	No hay cargo	No hay cargo	No hay cargo
Empaste sencilla	20%	20%	No hay cargo
La corona y el copal laboratorio	40%	50%	$42 - 73
Orthodontics	50%	50%	$350 para empezar $750 con bandas de elástico $150 por mes para 10 meses $2250 una vez para dos años
Periodontics	50%	50%	No hay cargo
Prosthodontics	40%	50%	$5 - 93
Tratamiento del nervio dental y molar	20%	50%	$9 - 96
Beneficios máximos pagados por año	$1000	$1000	No hay limite
El deducible	$50 por año. Renunciado para beneficios diagnósticos y preventivos.	$50 por año. Renunciado para beneficios diagnósticos y preventivos.	No hay deducible.

Delta covers this benefit only *after* 12 months of continuous enrollment.

Delta covers this benefit only *after* 12 months of continuous enrollment. Lifetime maximum of $1000.

Delta covers this benefit only *after* 12 months of continuous enrollment.

The Delta Dental plan includes only after* 12 months of continuous enrollment.

The Delta Dental plan includes only *after* 12 months of continuous enrollment. Lifetime maximum of $1000.

The Delta Dental plan includes only after* 12 months of continuous enrollment.

Overview of Delta and Pacific Union Dental Coverage Effective October 1, 2006