Dental Plan

Click here to view or download the Employee Per Pay Period Contributions document

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.