2025 - MIL-Tek USA OE Guide

Plan 2

Delta Dental PPO - EPO CP360 – Copay based plan

Deductible

$0

Preventive & Diagnostic Services

Exams, Cleanings, Routine X-rays, Sealants –

Basic Services

Fillings, Extractions, Periodontics, Root Canal –

Major Services

Crowns, Dentures, Bridges —

Orthodontia

Lifetime Maximum $2,000 per person -Orthodontic services – 50%

Annual Maximum

$2,000 per person

Monthly Payroll Deductions

Employee only - $20.05 Employee & Spouse - $42.10 Employee & Child(ren) - $44.11 Family—$68.15

For the services highlighted above, Delta Dental will pay the plan allowance minus any copay. Your payment responsibility is listed on the Schedule of Benefits, in addition to any amount over the benefit maximum.