Interactive Demonstration - Employer Connection

April 23, 2025

Benefits & Eligibility as of (mm/dd/yyyy)

Subscriber Name:	HARVEY J SCHNEIDER	Group Number:	93705-000-00000-00000
Coverage Type:	Single	Group Name:	FULLY INSURED

Please enter a procedure code.

Procedure Code: 00110

COVERAGE LEVELS

Procedure	Delta Premier	Out of Network	Comments
110	100%	100%	Deductible does not apply. Allowed at 6 month intervals.

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Delta Dental of Illinois is a part of Delta Dental Plans Association. Through our national network of Delta Dental
companies, we offer dental coverage in all 50 states, Puerto Rico and other U.S. territories.

Delta Dental of Illinois complies with all applicable Federal and State civil rights laws. Delta Dental of Illinois does not discriminate, exclude people, or treat them differently on the basis of gender, sex (which includes discrimination on the basis of sex characteristics, including intersex traits; pregnancy or related conditions; sexual orientation; gender identity or expression; and sex stereotypes), race, color, religious creed, national origin, citizenship, age, physical or intellectual disability, protected veteran status, marital status, genetic information, or any other characteristic protected by law.