Dental
Dental Plan Coverage Options
Delta Dental provides dental benefits. All active participants regardless of the medical plan option selected will have dental coverage. California participants will have a choice of coverage between Delta Preferred and Delta Care.
Delta Preferred (All participants)
This plan is a comprehensive dental care program, which provides reimbursement of covered dental expenses after satisfaction of a $75.00 per individual or $150.00 per family annual deductibleThe amount you must pay for covered services in a plan year before the plan begins to pay benefits. for services received from the dentistA doctor of dentistry who is licensed to practice dentistry at the time and place involved where the particular dental procedure was rendered. of your choice. The deductible is waived for diagnostic and preventive benefits. The level of reimbursement is dependent upon the nature of the services provided (diagnostic and preventive, basic, major, or orthodontia) with certain annual and lifetime maximum benefitThe maximum medical benefit payable by the Fund for a covered person throughout his/her lifetime. Once the lifetime benefit maximum is reached, no additional plan benefits will be paid. limitations.
DeltaCare (California participants only)
This plan is a dental HMO. You must enroll in this plan and select a dental office from the DeltaCare dental list. There is no annual deductible and no cost for covered services except for co-payments for certain procedures. Benefits are not available when services are obtained from a non-DeltaCare provider. Refer to the description of benefits and co-payments in the DeltaCare brochure.
Delta Preferred
| In Network | Out of Network | |
|---|---|---|
| Calendar Year Deductible | $75 per person $150 per family (does not apply to diagnostic and preventive services) |
$75 per person $150 per family (does not apply to diagnostic and preventive services) |
| Diagnostic and Preventive Benefits | 100% of Delta Preferred Option (DPO) approved fee (no deductible applies) | 80% of DPO approved fee (no deductible applies) |
| Basic and Major Benefits |
80% of DPO approved fee |
70% of DPO approved fee |
Orthodontia Benefits for individuals up to age 19 |
70% of DPO approved fee (subject to a $2,000 lifetime max. per person) |
70% of DPO approved fee (subject to a $2,000 lifetime max. per person) |
| Pedodontist* | 80% of DPO approved fee |
70% of DPO approved fee |
Maximums |
||
| Diagnostic, Preventative, Basic and Major Services | $2,500 per Calendar Year No annual or lifetime maximum applies to patients under the age of 18 |
$2,500 per Calendar Year No annual or lifetime maximum applies to patients under the age of 18 |
| Orthodontia | No annual or lifetime maximum applies to patients under the age of 18 | No annual or lifetime maximum applies to patients under the age of 18 |
Deltacare
| In Network | Out of Network | |
|---|---|---|
| Calendar Year Deductible | None | Services received from a non-DeltaCare dentist are not covered unless you have an accidental injuryBodily harm caused by an accident. The injury must also result, for the purposes of accidental death and dismemberment coverage, directly and independently of all other causes, in a loss covered by the plan. or emergency illness while you are temporarily out of town and more than 35 miles from a DeltaCare dental office. (Coverage is limited to $100 per occurrence.) |
| Diagnostic and Preventive Benefits | 100% | |
| Basic and Major Benefits | 100% | |
| Orthodontia Benefits for individuals up to age 19 ($25 calendar year deductible) | Up to age 19 – 100% after $350 startup fee – maximum co-pay of $1,600; Adults 100% after $350 startup fee – maximum co-pay of $1,800. | |
| Pedodontist* | Pedodontic referrals must be pre-authorized by DeltaCare. 100% of approved fee (less any applicable copayments) for ages 0-3 years, 50% of approved fee (less any applicable copayments for ages 4 and older.) |
* A pedodontist is a dentist that specializes in the growth and development of children's teeth.