DENTAL
Delta Dental Insurance

800-521-2651

Group #: 3939-0000

Full-time employees who actively work at least 30 hours per week are eligible for dental benefits, along with their legal spouse, dependent children up to age 26, and children of any age if they depend on the employee for support due to a disability. Coverage for new hires begins on the first of the month following their date of hire. Go back to Employee Benefits

Providers

You may select a dentist in either the PPO or Premier networks. Although dentists in both networks agree to accept a reduced fee for services, dentists in the PPO network agree to a lower fee then dentists in the Premier network. This means you will usually pay the lowest amount for services when you visit a dentist in the PPO network. The following chart shows an example of how this works:

Delta Dental PPO Dentists

Delta Dental PPO Dentists

Dentist bills:

$180.00

Dentist accepts as payment in full

$90.00 (Delta Dental’s agreed upon fee)

Delta Dental’s payment at 50%

$45.00

Patient share

$45.00

Delta Dental Premier Dentists

Delta Dental Premier Dentists

Dentist bills

$180.00

Dentist accepts as payment in full

$130.00 (Delta Dental’s agreed upon fee)

Delta Dental’s payment at 50%

$65.00

Patient share

$65.00

Employee Premiums

Single (Per Pay Period)

Single (Per Pay Period)

$6.25

Two-Party (Per Pay Period)

Two-Party (Per Pay Period)

$9.00

Family (Per Pay Period)

Family (Per Pay Period)

$16.25

Plan Information

Deductible:

Deductible of $50 per person with a family limit of $150 regardless of the number of patients in the family per calendar year.

Maximums:

There is an annual maximum benefit of $2,000 per person for services provided in a calendar year. There is also a separate lifetime maximum of $2,000 per patient for orthodontics.

Payment Schedule:

Benefits and Covered Services

Subject to Deductible

In-Network Payment Schedule

Out-of-Network Payment Schedule

Benefits and Covered Services

Diagnostic and Preventive Benefits*
Oral examinations, routine cleanings, x-rays, fluoride treatment for children, space maintainers

Subject to Deductible No

In-Network Payment Schedule 100%

Out-of-Network Payment Schedule 100% UCR**

Basic Benefits
Fillings, sealants, denture repairs, endodontics (root canals), periodontics (gum treatment)

Subject to Deductible Yes

In-Network Payment Schedule 80%

Out-of-Network Payment Schedule 80% UCR

Oral Surgery
Incisions, excisions, surgical removal of tooth

Subject to Deductible Yes

In-Network Payment Schedule 80%

Out-of-Network Payment Schedule 80% UCR

Major Benefits
Crowns, inlays, onlays, cast restorations, bridges, dentures, implants

Subject to Deductible Yes

In-Network Payment Schedule 50%

Out-of-Network Payment Schedule 50% UCR

Orthodontic Benefits
Adults and dependent children

Subject to Deductible No

In-Network Payment Schedule 50% (up to lifetime maximum)

Out-of-Network Payment Schedule 50% UCR (up to lifetime maximum)

* Limited to twice in 12-month calendar period.

**Usual, Customary, and Reasonable. You are responsible for the difference between the charged amount and the allowed (UCR) amount.

Resources

Delta Dental SPD
Download Now ▸
Where's My ID Card
Download Now ▸
Web and Mobile Resources
Download Now ▸