Your session is about to expire due to inactivity.
Health Fund

print

Dental Plan Benefits

Participants and covered dependents will automatically be enrolled in the Delta Preferred Option(DPO) if you are enrolled in the PPO Plan only. If you live in California you may choose to enroll in the DeltaCare USA Dental HMO (DHMO), a managed dental plan, instead. You also have the option of enrolling your eligible dependent(s) in the DHMO.

DELTA PREFERRED OPTION (DPO) DELTACARE
DPO Provider DELTA Dental Provider
(Not Part Of DPO Network)
Non-Network Provider DHMO 37 38
(Applies to California Only)
Plan Benefits
Diagnostic and Preventive Benefits 100% of DPO-
approved fee
(no deductible applies)
80% of Delta-
approved fee
(no deductible applies)
80% of Delta-
approved fee; you pay remaining 20% plus fees above approved amount
(See Delta Dental's Evidence of Coverage 40 (EOC) Schedule A for a description of benefits and copayments)
Basic and Major Benefits 80% of DPO-approved fee 70% of Delta-approved fee 70% of Delta-approved fee; you pay remaining 30% plus fees above approved amount (See Delta Dental's Evidence of Coverage 40 (EOC) Schedule A for a description of benefits and copayments)
Orthodontia Benefits 70% of DPO-approved fee (Coverage for
children up to age 19) 41

Benefits are limited to a $2000 lifetime maximum. 50% is payable at the time of banding and the remaining 50% twelve months later.
70% of Delta-approved fee (Coverage for children up to age 19) 41

Benefits are limited to a $2000 lifetime maximum. 50% is payable at the time of banding and the remaining 50% twelve months later.
70% of Delta-approved fee (Coverage for
children up to age 19) 41

Benefits are limited to a $2000 lifetime maximum. 50% is payable at the time of banding and the remaining 50% twelve months later.
Dental Work Performed by a Pedodontist 42 Percentage of approved fee varies based on type of service Percentage of approved fee varies based on type of service Percentage of approved fee varies based on type of service

Pedodontic referrals must be pre-authorized by DeltaCare.

  • Up to age 7: 100% less applicable co-payments following an attempt by the assigned contracted dentist to treat the child and upon prior authorization by DeltaCare USA. Exceptions for medical conditions, regardless of age limitation, will be considered on an individual basis.


IMPORTANT!
The following are covered under the Preventive Care Services benefit at 100%, with no deductible:
   - Fluoride supplements for children without fluoride in their local water supply.
   - Oral health risk assessment for young children.


37. Services received from a non-network dentist are not covered, except in an emergency if your DeltaCare dentist is unavailable or cannot see you within 24 hours of making contact or you believe your condition makes it dentally/medically inappropriate to travel to your contracted dentist to receive emergency services.

38. The plan will reimburse up to $100 of non-network emergency dental care per emergency, per enrollee, less any applicable copayment.

39. Plan maximum annual dollar limit does not apply to dependent children under the age of 19. Exception for Orthodontia Benefits will be limited to the lifetime maximum of $2000.

40. The Delta Dental EOC was distributed at the time of enrollment. If another copy is needed, contact DeltaCare USA Customer Relations at (800) 422-4234 or website, www.wgaplans.org.

41. Up to age 19 with a $25 deductible.

42. A Pedodontist is a dentist who specializes in the growth and development of children's teeth.