Single Person: $31.00 Two People: $51.00 Family Plan: $84.00 *12 Month Commitment applies to this plan Hearing Aid Discount Free Phone Consultation on Medicaid Planning Receive Prescription Discounts Vitamin Discounts 24 Hour Nurse Hotline Dental Benefits for the Silver Plan Preventive Services: Examples PPO Premier Preventive & Diagnostic Fluorides Emergency Palliative X-Rays Sealants 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% Basic Services: Examples PPO Premier Periodontic Prophylaxes Minor Restorative Simple Periodontics Major Periodontics Endodontics Oral Surgery Relines & Repairs 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% Major Services: Examples PPO Premier Major Restorative Stainless Steel Crowns Prosthodontics 25% 25% 25% 25% 25% 25% Insurance will be effective the first day of the upcoming month. Delta Dental Application Form *This web page is for illustrative purposes only. You will receive benefit booklets. If there is a discrepancy between this web page and your benefit booklet, the benefit booklet prevails. Renewal rates are effective for 8/15/2010