Dental Plan
Our dental plans consist of two choices: a Dental Health Maintenance Organization (DHMO) Plan and a Preferred Provider Organization (PPO) plan, both offered by Delta Dental. The DHMO Plan requires you to elect a Primary Care Dentist (see Delta Delta Dental DHMO Plan Summary here). If the employee selects the PPO, they may use any dental care provider. However, when electing a provider within the Delta dental PPO network, the out-of-pocket costs will likely be lower than if an out-of-network provider is used.
| Delta Dental Plans Phone #: 800-422-4234 |
DHMO* Policy #: 70235 |
PPO Policy #: 23523 |
||
|---|---|---|---|---|
| Deductibles:
per member / per family each contract year |
None | Delta Dental PPO dentists** | Delta Dental Premier dentists** | Non-Delta Dental dentists** |
| $50/ $150 | $50/ $150 | $50/ $150 | ||
| Deductibles waived for Diagnostic & Preventive | ||||
| Annual Maximum | Unlimited | $1,500 | $1,500 | $1,500 |
| D&P counts toward maximum | ||||
| Diagnostic & Preventive Services (D&P)
Exams, Cleanings, X-Rays, Sealants and Space Maintainers |
See Fee Schedule | 100% | 80% | 80% |
| Basic Services
Fillings, Simple Extractions, Posterior Composites and Denture Repair/Reline/Rebase |
See Fee Schedule | 80% | 80% | 80% |
| Endodontics
Root Canals |
See Fee Schedule | 80% | 80% | 80% |
| Periodontics
Surgical and Non-Surgical Periodontics |
See Fee Schedule | 80% | 80% | 80% |
| Oral Surgery | See Fee Schedule | 80% | 80% | 80% |
| Major Services
Crowns, Inlays, Onlays and Cast Restorations |
See Fee Schedule | 50% | 50% | 50% |
| Prosthodontics
Bridges and Dentures |
See Fee Schedule | 50% | 50% | 50% |
For eligibility details, refer to the plan's Evidence/Certificate of Coverage (on file with your benefits administrator, plan sponsor or employer).
* Limitations or waiting periods may apply for some benefits; some services may be excluded from your plan. Reimbursement is based on Delta Dental maximum contract allowances and not necessarily each dentist’s submitted fees.
** Reimbursement is based on PPO contracted fees for PPO dentists, Premier contracted fees for Premier dentists and program allowance for non-Delta Dental dentists.
