Verdugo Hills dental plan

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

BENEFIT In‐network (Delta Dental provider) Out‐of‐network
Deductible Individual / family $50 / $150
Maximum $1500 per person per calendar year (maximum payments to an out‐of‐network provider: $1000)
Waiting periods None
Diagnostic and preventive services

ž Routine oral exams

ž Cleaning / scaling

ž Bite‐wing and full‐mouth X‐rays

ž Space maintainers

ž Fluoride treatment

100% (deductible waived) 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

80% 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

50% 50% of the lesser of the fee actually charged, or the fee that satisfies the majority of Delta Dental dentists
Orthodontic benefits (children only) 50% 50% of the lesser of the fee actually charged, or the fee that satisfies the majority of Delta Dental dentists
Orthodontic lifetime maximum $1000 per person

Delta Dental | www.deltadentalins.com

(800) 765-6003

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