Forms & Documents

Summary of Benefits (SOB)

Dental PPO w/Ortho: Delta Dental

	PPO Plus Premier Deluxe 200 Voluntary | $1500 Max | $1500 Child Ortho SOB
	PPO Plus Premier Deluxe 200 Voluntary | $2000 Max | $1500 Child and Adult Ortho SOB
	PPO Plus Premier Deluxe 200 Voluntary | $2000 Max | $1500 Child Ortho SOB
	PPO Plus Premier Deluxe 200 Voluntary | $2500 Max | $1500 Child and Adult Ortho SOB
	PPO Plus Premier Deluxe 200 Voluntary | $2500 Max | $1500 Child Ortho SOB
	PPO Plus Premier Deluxe 200 Voluntary | $3000 Max | $1500 Child and Adult Ortho SOB
	PPO Plus Premier Deluxe 200 Voluntary | $3000 Max | $1500 Child Ortho SOB
	PPO Plus Premier Deluxe 200 Voluntary | $3000 Max SOB
	PPO Plus Premier Dual Choice 2 | $1500 Max | $1000 Ortho SOB
	PPO Plus Premier Dual Choice 2 | $1500 Max | D&P Max Waiver | $1000 Ortho SOB
	PPO Plus Premier Dual Choice 2 | $2000 Max | $1000 Ortho SOB
	PPO Plus Premier Dual Choice 2 | $2000 Max | D&P Max Waiver | $1000 Ortho SOB
	PPO Plus Premier Dual Choice 2 Voluntary | $1500 Max | $1000 Ortho SOB
	PPO Plus Premier Dual Choice 2 Voluntary | $2000 Max | $1000 Ortho SOB
	PPO Plus Premier Dual Choice 3 High | $1500 Max | $1500 Ortho SOB
	PPO Plus Premier Dual Choice 3 High | $1500 Max | D&P Max Waiver | $1500 Ortho SOB
	PPO Plus Premier Dual Choice 3 High | $2500 Max | $1500 Ortho SOB
	PPO Plus Premier Dual Choice 3 High | $2500 Max | D&P Max Waiver | $1500 Ortho SOB
	PPO Plus Premier Dual Choice 3 Low | $1000 Max | $1000 Ortho SOB
	PPO Plus Premier Dual Choice 3 Low | $1000 Max | $1000 Ortho SOB
	PPO Plus Premier Dual Choice 3 Low | $1000 Max | D&P Max Waiver | $1000 Ortho SOB
	PPO Plus Premier Dual Choice 3 Low | $1500 Max | $1000 Ortho SOB
	PPO Plus Premier Dual Choice 3 Low | $1500 Max | D&P Max Waiver | $1000 Ortho SOB
	PPO Plus Premier Dual Choice 3 Voluntary | $1000 Max | $100 Ortho SOB - needs to be $1000 ortho
	PPO Plus Premier Dual Choice 3 Voluntary | $1500 Max | $1000 Ortho SOB
	PPO Plus Premier Dual Choice 3 Voluntary | $1500 Max | $1500 Ortho SOB
	PPO Plus Premier Dual Choice 3 Voluntary | $2500 Max | $1500 Ortho SOB
	PPO Plus Premier Dual Choice Buy-up | $1500 Max | $1500 Ortho SOB
	PPO Plus Premier Dual Choice Buy-up | $2000 Max | $1500 Ortho SOB
	PPO Plus Premier Dual Choice Core | $1000 Max | $1000 Ortho SOB