Your dental coverage is provided through the Delta Dental Preferred Option (PPO) Plan. Our Plan allows you to see any licensed dentist, but the Plan pays increased benefits when you use a Delta Dental PPO dentist.
|Delta Dental PPO dentists*||Delta Dental Premier dentists*||Non-Delta Dental PPO dentists*|
|Deductible||None||$50 per person / $100 family each calendar year||$50 per person / $100 family each calendar year|
|Diagnostic & Preventive Services Exams, cleanings, x-rays, sealants||100%||100%||100%|
|Basic Services Fillings, simple tooth extractions, night guards||90%||80%||80%|
|Major Services Crowns, inlays, onlays and cast restorations, bridges and dentures, implants||60%||50%||50%|
|Orthodontic Maximum||$2,000 Lifetime||$2,000 Lifetime||$2,000 Lifetime|
*Reimbursement is based on PPO contracted fees for PPO dentists, Premier contracted fees for Premier dentists and program allowance for non-Delta Dental dentists.
For additional details about the dental plan including what is excluded, see the documents provided below under “Guides”.
You may elect to cover yourself only or yourself and any eligible dependents. Below is the cost per paycheck. Any premiums paid by you – other than for domestic partner coverage – are on a pre-tax basis.
|Dental coverage level||Delta Dental PPO|
|You + spouse/domestic partner||$9.53|
|You + children||$10.27|
|You + spouse/domestic partner + up to 2 children||$16.94|
|You + spouse/domestic partner + 3 or more children||$20.33|
* You must generally pay for coverage of a domestic partner and a domestic partner's children on a post-tax basis, and the value of the Company subsidy, if any, must generally be included in your taxable income. This is called "imputed income." Contact your tax advisor for more information.
If you see a Delta Dental PPO Dentist:
- PPO dentists agree to accept a reduced fee for PPO patients. You will usually pay the lowest amount for services when you visit a Delta Dental PPO dentist.
- You are charged only the patient’s share at the time of treatment. Delta Dental pays the Plan’s portion directly to the dentist.
- PPO dentists will complete claim forms and submit them for you at no charge.
If you see a Non-PPO Delta Dental dentist (includes Delta Dental Premier Dentists and Non-Delta Dental Dentists):
- You are responsible for the difference between the allowed amount the Plan pays and the amount the dentist bills. You will usually have the highest out-of-pocket costs when you visit a non-Delta Dental PPO dentist. Premier dentists may not balance bill above Delta Dental’s approved amount, so your out-of-pocket costs may be lower than with non-Delta Dental dentists’ charges.
- Non-Delta Dental dentists may require you to pay the entire amount of the bill in advance and wait for reimbursement. Premier dentists charge you only the patient’s share at the time of treatment.
- You may have to complete and submit your own claim forms. Premier dentists will complete the claim forms and submit them for you at no charge.
The Delta Dental website, deltadentalins.com, allows you to manage your dental benefits online. You may register to view your policy information, check the status of a claim, or gain access to your enrollment information and print out an ID card.
Review the Dental Benefits Highlights for more information.
Review the Evidence of Coverage for dental plan details.