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Health Fund

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Dental Plan Features

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 Features
Calendar-Year
DeductibleThe amount you must pay for covered services in a plan year before the plan begins to pay benefits.
$75/person or
$150/family
(doesn't apply to diagnostic and preventive services)
$75/person or
$150/family
(doesn't apply to diagnostic and preventive services)
$75/person or
$150/family
(doesn't apply to diagnostic and preventive services)
None
Plan Maximum:
  • Diagnostic, Preventive, Basic and Major Services
$2,500/
calendar year 39
$2,500/
calendar year 39
$2,500/
calendar year 39
Unlimited
  • Orthodontia
Coverage for children
up to the age 19
$2,000 Lifetime maximum
Coverage for children
up to the age 19
$2,000 Lifetime maximum
Coverage for children
up to the age 19
$2,000 Lifetime maximum
(See Delta Dental’s Evidence of Coverage(EOC) Schedule A for a description of benefits and copayments.)


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.